Basic Information
| Provider Information | |||||||||
| NPI: | 1629059761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENNO-OLIVET RETIREMENT HOME INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MENNO-OLIVET CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 487 | ||||||||
| Address2: | |||||||||
| City: | MENNO | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570450487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053875139 | ||||||||
| FaxNumber: | 6053872441 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 SOUTH PINE STREET | ||||||||
| Address2: | |||||||||
| City: | MENNO | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570450487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053875139 | ||||||||
| FaxNumber: | 6053872441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 06/22/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEADLEY | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6053875139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 10648 | SD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0160260 | 05 | SD | MEDICAID |