Healthcare Provider Details

I. General information

NPI: 1366412348
Provider Name (Legal Business Name): PRESBYTERIAN RETIREMENT VILLAGE OF RAPID CITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MOUNTAIN VIEW RD
RAPID CITY SD
57702-3421
US

IV. Provider business mailing address

1015 MOUNTAIN VIEW RD
RAPID CITY SD
57702-3421
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-5882
  • Fax: 605-348-5787
Mailing address:
  • Phone: 605-343-5882
  • Fax: 605-348-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10666
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier0151072
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: DARYL REINICKE
Title or Position: CEO
Credential:
Phone: 605-343-5882