Basic Information
| Provider Information | |||||||||
| NPI: | 1457425704 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MITCHELL HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FIRESTEEL HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 E 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573012908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059966526 | ||||||||
| FaxNumber: | 6059968290 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 E 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573012908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059966526 | ||||||||
| FaxNumber: | 6059968290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOERBOOM | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9528737907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSION HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | 10653 | SD | N | Agencies | Nursing Care | 314000000X | 10653 | SD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0150912 | 05 | SD | MEDICAID |