Provider Demographics
NPI:1356342851
Name:LAKE ANDES HEALTH CARE CENTER, INC.
Entity type:Organization
Organization Name:LAKE ANDES HEALTH CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-487-7674
Mailing Address - Street 1:740 E LAKE ST
Mailing Address - Street 2:PO BOX 216
Mailing Address - City:LAKE ANDES
Mailing Address - State:SD
Mailing Address - Zip Code:57356-2001
Mailing Address - Country:US
Mailing Address - Phone:605-487-7674
Mailing Address - Fax:605-487-7071
Practice Address - Street 1:740 E LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE ANDES
Practice Address - State:SD
Practice Address - Zip Code:57356-2001
Practice Address - Country:US
Practice Address - Phone:605-487-7674
Practice Address - Fax:605-487-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10638314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0151190Medicaid
SD85097OtherBLUE CROSS BLUE SHIELD
SD85097OtherBLUE CROSS BLUE SHIELD