Healthcare Provider Details

I. General information

NPI: 1669607453
Provider Name (Legal Business Name): SOUTHEAST DAKOTA HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 5TH AVE STE. 3
MITCHELL SD
57301-2652
US

IV. Provider business mailing address

200 E 5TH AVE STE. 3
MITCHELL SD
57301-2652
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-0503
  • Fax: 605-996-0310
Mailing address:
  • Phone: 605-996-0503
  • Fax: 605-996-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9550620
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: MRS. JAN FAE JERKE
Title or Position: PARTNER
Credential:
Phone: 605-996-0503