MEDICARE: WESTERN RESOURCES FOR INDEPENDENT LIVING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency
2	385H00000X	Respite Care

General Provider Information

NPI Number	:	1497009732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN RESOURCES FOR INDEPENDENT LIVING

Provider Business Mailing Address
First Line	:	405 E OMAHA ST
Second Line	:	SUITE D
City	:	RAPID CITY
State	:	SD
Zip	:	57701-2975
Country	:	US
Telephone Number	:	605-718-1930
Fax Number	:	605-718-1933

Provider Business Practice Location Address
First Line	:	4110 WINFIELD CT
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-8306
Country	:	US
Telephone Number	:	605-791-3383
Fax Number	:	605-791-3385

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ANN VAN LOAN
Credential	:
Telephone Number	:	605-718-1930

Provider Enumeration Date	:	11/08/2012
Last Update Date	:	03/25/2015

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