Healthcare Provider Details

I. General information

NPI: 1124586037
Provider Name (Legal Business Name): VISTA CARE SOUTH DAKOTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2019
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 ERIE AVE
SHEBOYGAN WI
53081-4060
US

IV. Provider business mailing address

708 ERIE AVE
SHEBOYGAN WI
53081-4060
US

V. Phone/Fax

Practice location:
  • Phone: 920-694-1102
  • Fax: 920-694-4685
Mailing address:
  • Phone: 920-694-1102
  • Fax: 920-694-4685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. TIMOTHY ALAN FREY
Title or Position: PRESIDENT
Credential:
Phone: 920-694-1102