Healthcare Provider Details

I. General information

NPI: 1174555858
Provider Name (Legal Business Name): SPEARFISH HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 NORTH 10TH STREET
SPEARFISH SD
57783-2203
US

IV. Provider business mailing address

1020 NORTH 10TH STREET
SPEARFISH SD
57783-2203
US

V. Phone/Fax

Practice location:
  • Phone: 605-642-2716
  • Fax: 605-722-0757
Mailing address:
  • Phone: 605-642-2716
  • Fax: 605-722-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10686
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier85043
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerWELLMARK
# 2
Identifier0150412
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