NPIMap

Organization Active NPI

Clark City SD Skilled Nursing Facility LLC

Doing business as Avantara Clark City

  • Skilled Nursing Facility
  • Clark, SD
National Provider Identifier
1649836164
Registry record updated May 10, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
CLARK CITY SD SKILLED NURSING FACILITY LLC
Doing business as
Avantara Clark City
Practice address
201 8TH Ave NW
Clark, SD 57225-1147
Phone
(605) 532-3431
Fax
(605) 532-3433
NPI assigned
May 10, 2019
Last updated
May 10, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 10, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Menachem Shabat
Title
Coo/Principal
Phone
(847) 679-9797

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

201 8TH Ave NW
Clark, SD 57225-1147

Mailing address

3450 Oakton St
Skokie, IL 60076-2951
Phone (847) 679-9797

Other names 1

  • Avantara Clark City Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190826001446 SD Part A Provider - Skilled Nursing Facility 5092043232 Practice locations: Clark, SD

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649836164. Details of each certification follow.

Skilled nursing facility certification: CCN 435058

Legal name
CLARK CITY SD SKILLED NURSING FACILITY LLC
Doing business as
AVANTARA CLARK CITY
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
May 1, 1991
Last certification
Sep 12, 2024
Beds
35
Ownership / control type
Limited Liability Corporation
Multi-facility organization
Legacy Healthcare
Organization structure
LLCProprietary
Enrollment address
201 8TH Ave NW
Clark, SD 57225-1147
Nursing home name
AVANTARA CLARK CITY
Affiliated entity
LEGACY HEALTHCARE

Care Compare: Nursing home

Medicare Care Compare
Listed as
Avantara Clark CityCCN 435058 · All quality measures
Overall star rating
4 of 5
Health inspections
4 of 5
Staffing
2 of 5
Quality measures
2 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
May 1, 1991
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
3529.3 residents per day on average
Chain
Legacy Healthcare89 facilities in the chain
Penalties (3 years)
1Fines totaling $11,057

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
43D2168191Avantara Clark201 8TH St NW, Clark, SD 57225Certificate of waiverJun 23, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Bokf,NA Organization, Tulsa, OK Financial institution 5% Or Greater Security Interest Mar 4, 2024 100%
Operational/Managerial Control Mar 4, 2024
Clark City SD Property Holdings, LLC Organization, Skokie, IL LLC Adp of the SNF Jul 1, 2019
Individual Indirect Ownership Interest Jul 1, 2019 4.9%
Menachem Shabat Individual Operational/Managerial Control Jul 1, 2019
Managing Control - Governing BodyManager of the Manager Jul 1, 2019
Adp of the SNF Jul 1, 2019
Roth & Co, LLP Organization, Brooklyn, NY Consulting firm Adp of the SNF Jan 1, 2024
Individual Indirect Ownership Interest Jul 1, 2019 2.6%
Chaim Rajchenbach Individual Operational/Managerial Control Jul 1, 2019
Managing Control - Governing BodyManager of the Manager Jul 1, 2019
Adp of the SNF Jul 1, 2019
GPN Family Trust U/a/D 4/28/08 Organization, Skokie, IL 5% Or Greater Direct Ownership Interest Jul 1, 2019 42.5%
Adp of the SNF Jul 1, 2019
Individual Indirect Ownership Interest Jul 1, 2019 4.9%
Legacy Healthcare Financial Services LLC Organization, Skokie, IL LLC, For-profit Adp of the SNF Jul 1, 2019
Oakway Operations LLC Organization, Skokie, IL LLC 5% Or Greater Direct Ownership Interest Jul 1, 2015 15%
Doros Generation Trust U/a/D 1/3/12 Organization, Skokie, IL 5% Or Greater Direct Ownership Interest Jul 1, 2019 42.5%
Adp of the SNF Jul 1, 2019
Rachel Morehouse Individual Operational/Managerial Control Jan 6, 2020
Adp of the SNF Jan 6, 2020
Edward a Dickes Individual Operational/Managerial Control Jan 1, 2025
Adp of the SNF Jan 1, 2025
Individual Indirect Ownership Interest Jul 1, 2019 2.6%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 85

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 85

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1557446400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1557446400000",
    "number": "1649836164",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3450 OAKTON ST",
            "city": "SKOKIE",
            "state": "IL",
            "postal_code": "600762951",
            "telephone_number": "847-679-9797",
            "fax_number": "847-679-1126"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 8TH AVE NW",
            "city": "CLARK",
            "state": "SD",
            "postal_code": "572251147",
            "telephone_number": "605-532-3431",
            "fax_number": "605-532-3433"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLARK CITY SD SKILLED NURSING FACILITY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-05-10",
        "last_updated": "2019-05-10",
        "status": "A",
        "authorized_official_last_name": "SHABAT",
        "authorized_official_first_name": "MENACHEM",
        "authorized_official_title_or_position": "COO/PRINCIPAL",
        "authorized_official_telephone_number": "847-679-9797"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Avantara Clark City",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clark, SD

Sources for this page

Verify at the official NPI Registry.