MEDICARE: INNER-MOUNTAIN FAMILY RESOURCES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	410411	SD

General Provider Information

NPI Number	:	1083738876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER-MOUNTAIN FAMILY RESOURCES, INC.

Provider Business Mailing Address
First Line	:	23812 COUNTY ROAD 30.5
Second Line	:
City	:	LA JUNTA
State	:	CO
Zip	:	81050-9280
Country	:	US
Telephone Number	:	645-645-2598
Fax Number	:	719-384-7092

Provider Business Practice Location Address
First Line	:	608 5TH AVE
Second Line	:
City	:	BELLE FOURCHE
State	:	SD
Zip	:	57717-1214
Country	:	US
Telephone Number	:	605-892-3039
Fax Number	:	605-892-3158

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	DR. CHARLES DAVID WALLIN
Credential	:	EDD, MSW
Telephone Number	:	605-645-2598

Provider Enumeration Date	:	03/18/2007
Last Update Date	:	08/22/2020

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