Provider Demographics
NPI:1992975627
Name:MEADOW LAKE ASSISTED LIVING
Entity type:Organization
Organization Name:MEADOW LAKE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-882-4388
Mailing Address - Street 1:17444 MEADOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-9181
Mailing Address - Country:US
Mailing Address - Phone:605-882-4388
Mailing Address - Fax:605-882-4388
Practice Address - Street 1:17444 MEADOW LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-9181
Practice Address - Country:US
Practice Address - Phone:605-882-4388
Practice Address - Fax:605-882-4388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10727310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570730Medicaid