Healthcare Provider Details

I. General information

NPI: 1346495017
Provider Name (Legal Business Name): WISDOM IN AGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2008
Last Update Date: 11/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 W MAIN ST
RAPID CITY SD
57702-2139
US

IV. Provider business mailing address

3704 W MAIN ST
RAPID CITY SD
57702-2139
US

V. Phone/Fax

Practice location:
  • Phone: 605-721-9473
  • Fax:
Mailing address:
  • Phone: 605-721-9473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number47608
License Number StateSD

VIII. Authorized Official

Name: MS. VICKI L KENNEDY
Title or Position: MANAGER
Credential:
Phone: 605-721-9473