Provider Demographics
NPI:1295090082
Name:WELLSPRING, INC.
Entity type:Organization
Organization Name:WELLSPRING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:VAN HUNNIK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:605-718-4870
Mailing Address - Street 1:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-1087
Mailing Address - Country:US
Mailing Address - Phone:605-718-4870
Mailing Address - Fax:605-718-4878
Practice Address - Street 1:1205 E SAINT JAMES ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3958
Practice Address - Country:US
Practice Address - Phone:605-342-0345
Practice Address - Fax:605-718-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility