Provider Demographics
NPI:1174555858
Name:SPEARFISH HEALTHCARE, LLC
Entity type:Organization
Organization Name:SPEARFISH HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOERBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-873-7907
Mailing Address - Street 1:1020 NORTH 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2203
Mailing Address - Country:US
Mailing Address - Phone:605-642-2716
Mailing Address - Fax:605-722-0757
Practice Address - Street 1:1020 NORTH 10TH STREET
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2203
Practice Address - Country:US
Practice Address - Phone:605-642-2716
Practice Address - Fax:605-722-0757
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSION HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-06
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10686314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD85043OtherWELLMARK
SD0150412Medicaid
SD85043OtherWELLMARK