Healthcare Provider Details

I. General information

NPI: 1518738582
Provider Name (Legal Business Name): WONDERFUL-HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7708 W ELI CT
SIOUX FALLS SD
57106-7203
US

IV. Provider business mailing address

7708 W ELI CT
SIOUX FALLS SD
57106-7203
US

V. Phone/Fax

Practice location:
  • Phone: 267-304-8811
  • Fax:
Mailing address:
  • Phone: 267-304-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ANGIE K LEWIS
Title or Position: CO-OWNER
Credential:
Phone: 267-304-8811