Healthcare Provider Details

I. General information

NPI: 1063475812
Provider Name (Legal Business Name): BELLE FOURCHE HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 - 13TH AVENUE
BELLE FOURCHE SD
57717-2215
US

IV. Provider business mailing address

2200 - 13TH AVENUE
BELLE FOURCHE SD
57717-2215
US

V. Phone/Fax

Practice location:
  • Phone: 605-892-3331
  • Fax: 605-723-0204
Mailing address:
  • Phone: 605-892-3331
  • Fax: 605-723-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10594
License Number StateSD

VIII. Authorized Official

Name: MR. THOMAS E. BOERBOOM
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 952-873-7907