Provider Demographics
NPI:1699159236
Name:MEDICINE WHEEL VILLAGE
Entity type:Organization
Organization Name:MEDICINE WHEEL VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTED LIVING ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLOWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-964-8155
Mailing Address - Street 1:24266 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625
Mailing Address - Country:US
Mailing Address - Phone:605-964-8155
Mailing Address - Fax:605-964-8158
Practice Address - Street 1:24266 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-8155
Practice Address - Fax:605-964-8158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD65643310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility