=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699159236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICINE WHEEL VILLAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2015
-----------------------------------------------------
Last Update Date | 07/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24266 AIRPORT RD
-----------------------------------------------------
City | EAGLE BUTTE
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-964-8155
-----------------------------------------------------
Fax | 605-964-8158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24266 AIRPORT RD
-----------------------------------------------------
City | EAGLE BUTTE
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-964-8155
-----------------------------------------------------
Fax | 605-964-8158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTED LIVING ADMINISTRATOR
-----------------------------------------------------
Name | MRS. KIMBERLY D CLOWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 605-964-8155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 65643
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------