Provider Demographics
NPI:1720143316
Name:FAY WOOKEY MEMORIAL, INC.
Entity Type:Organization
Organization Name:FAY WOOKEY MEMORIAL, INC.
Other - Org Name:FAY WOOKEY MEMORIAL ASSISTED LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:DONETTE
Authorized Official - Last Name:WOOKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-532-5799
Mailing Address - Street 1:700 N SMITH ST
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:SD
Mailing Address - Zip Code:57225-1120
Mailing Address - Country:US
Mailing Address - Phone:605-532-5799
Mailing Address - Fax:605-532-1320
Practice Address - Street 1:700 N SMITH ST
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:SD
Practice Address - Zip Code:57225-1120
Practice Address - Country:US
Practice Address - Phone:605-532-5799
Practice Address - Fax:605-532-1320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11038310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570180Medicaid