Provider Demographics
NPI:1871600759
Name:ROSHOLT COUNTRY INN
Entity type:Organization
Organization Name:ROSHOLT COUNTRY INN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER - OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:VANDEPUTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-537-4588
Mailing Address - Street 1:208 PRAIRIE AVE
Mailing Address - Street 2:PO BOX 218
Mailing Address - City:ROSHOLT
Mailing Address - State:SD
Mailing Address - Zip Code:57260-0218
Mailing Address - Country:US
Mailing Address - Phone:605-537-4588
Mailing Address - Fax:605-537-4890
Practice Address - Street 1:208 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:ROSHOLT
Practice Address - State:SD
Practice Address - Zip Code:57260-0218
Practice Address - Country:US
Practice Address - Phone:605-537-4588
Practice Address - Fax:605-537-4890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD53737310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570820Medicaid