Healthcare Provider Details

I. General information

NPI: 1104814672
Provider Name (Legal Business Name): WHITE HEALTHCARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATRICKS AVE
WHITE SD
57276-2047
US

IV. Provider business mailing address

200 PATRICKS AVE
WHITE SD
57276-2047
US

V. Phone/Fax

Practice location:
  • Phone: 605-629-8871
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number05001460340865EUT001
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier9572020
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier0160230
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 3
Identifier85111
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name: HOWIE GROFF
Title or Position: PRESIDENT
Credential:
Phone: 952-888-2923