Provider Demographics
NPI:1063562437
Name:EASTERN STAR HOME OF SOUTH DAKOTA INC.
Entity type:Organization
Organization Name:EASTERN STAR HOME OF SOUTH DAKOTA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-472-0658
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:REDFIELD
Mailing Address - State:SD
Mailing Address - Zip Code:57469-1522
Mailing Address - Country:US
Mailing Address - Phone:605-472-0658
Mailing Address - Fax:605-472-3590
Practice Address - Street 1:126 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:REDFIELD
Practice Address - State:SD
Practice Address - Zip Code:57469-1522
Practice Address - Country:US
Practice Address - Phone:605-472-0658
Practice Address - Fax:605-472-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9570590310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570590Medicaid