Basic Information
| Provider Information | |||||||||
| NPI: | 1639264765 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST BENEDICT HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERA BORMANN MANOR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 401 W GLYNN DR | ||||||||
| Address2: | |||||||||
| City: | PARKSTON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573669605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059283311 | ||||||||
| FaxNumber: | 6059287368 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W GLYNN DR | ||||||||
| Address2: | |||||||||
| City: | PARKSTON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573669605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059283311 | ||||||||
| FaxNumber: | 6059287368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | GALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6059283311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 10660 | SD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.