Provider Demographics
NPI:1124027586
Name:STATE OF SOUTH DAKOTA
Entity type:Organization
Organization Name:STATE OF SOUTH DAKOTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GEISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-668-3148
Mailing Address - Street 1:PO BOX 7600
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-7600
Mailing Address - Country:US
Mailing Address - Phone:605-668-3148
Mailing Address - Fax:605-668-5407
Practice Address - Street 1:3515 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-7600
Practice Address - Country:US
Practice Address - Phone:605-668-3148
Practice Address - Fax:605-668-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10577283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0240070Medicaid
434003Medicare ID - Type Unspecified