Provider Demographics
NPI:1447480454
Name:TIESZEN MEMORIAL HOME INC
Entity type:Organization
Organization Name:TIESZEN MEMORIAL HOME INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICERS
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:I
Authorized Official - Last Name:ENGBRECHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-648-3611
Mailing Address - Street 1:101 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:SD
Mailing Address - Zip Code:57053-2163
Mailing Address - Country:US
Mailing Address - Phone:605-648-3611
Mailing Address - Fax:605-648-3363
Practice Address - Street 1:312 E STATE ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SD
Practice Address - Zip Code:57043-2011
Practice Address - Country:US
Practice Address - Phone:605-648-3611
Practice Address - Fax:605-648-3363
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIESZEN MEMORIAL HOME INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD50689310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570600Medicaid