Provider Demographics
NPI:1649268608
Name:CITY OF ESTELLINE
Entity type:Organization
Organization Name:CITY OF ESTELLINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-873-2278
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:ESTELLINE
Mailing Address - State:SD
Mailing Address - Zip Code:57234-0130
Mailing Address - Country:US
Mailing Address - Phone:605-873-2278
Mailing Address - Fax:605-873-2989
Practice Address - Street 1:205 FJERESTAD AVE E
Practice Address - Street 2:
Practice Address - City:ESTELLINE
Practice Address - State:SD
Practice Address - Zip Code:57234-2103
Practice Address - Country:US
Practice Address - Phone:605-873-2278
Practice Address - Fax:605-873-2989
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITY OF ESTELLINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-12
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11067310400000X
SD10617313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0151140Medicaid
SD0151140Medicaid