Provider Demographics
NPI:1316683204
Name:GREAT PLAINS AREA YOUTH REGIONAL TREATMENT CENTER
Entity type:Organization
Organization Name:GREAT PLAINS AREA YOUTH REGIONAL TREATMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAVON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-845-7181
Mailing Address - Street 1:PO BOX 680
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-0680
Mailing Address - Country:US
Mailing Address - Phone:605-850-8249
Mailing Address - Fax:
Practice Address - Street 1:12451 HWY 1806 N
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-5760
Practice Address - Country:US
Practice Address - Phone:605-845-7181
Practice Address - Fax:605-845-5072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-12
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5095050Medicaid
SD2022304Medicaid