Healthcare Provider Details

I. General information

NPI: 1750386660
Provider Name (Legal Business Name): RAPID CITY HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 WESLEYAN BLVD
RAPID CITY SD
57702-9340
US

IV. Provider business mailing address

2000 WESLEYAN BLVD
RAPID CITY SD
57702-9340
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-3555
  • Fax: 605-348-1979
Mailing address:
  • Phone: 605-343-3555
  • Fax: 605-348-1979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10723
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier0151303
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier0151302
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

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