Healthcare Provider Details

I. General information

NPI: 1871600759
Provider Name (Legal Business Name): ROSHOLT COUNTRY INN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 PRAIRIE AVE
ROSHOLT SD
57260-0218
US

IV. Provider business mailing address

208 PRAIRIE AVE PO BOX 218
ROSHOLT SD
57260-0218
US

V. Phone/Fax

Practice location:
  • Phone: 605-537-4588
  • Fax: 605-537-4890
Mailing address:
  • Phone: 605-537-4588
  • Fax: 605-537-4890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number53737
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number53737
License Number StateSD

VIII. Authorized Official

Name: MR. CHARLES WILLIAM VANDEPUTTE
Title or Position: OWNER - OPERATOR
Credential:
Phone: 605-537-4588