Provider Demographics
NPI:1740473115
Name:STATE TREATMENT AND REHABILITATION ACADEMY
Entity type:Organization
Organization Name:STATE TREATMENT AND REHABILITATION ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-673-2521
Mailing Address - Street 1:12279 BRADY DR
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-9160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25292 BADGER CLARK RD
Practice Address - Street 2:
Practice Address - City:CUSTER
Practice Address - State:SD
Practice Address - Zip Code:57730-8244
Practice Address - Country:US
Practice Address - Phone:605-255-4937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5160390Medicaid