1487640132 NPI number — FOUNDATION FOR RURAL HEALTH CARE

Table of content: (NPI 1487640132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487640132 NPI number — FOUNDATION FOR RURAL HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNDATION FOR RURAL HEALTH CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CRESTVIEW MANOR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487640132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 W 155TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURNSVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55306-5405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-435-7371
Provider Business Mailing Address Fax Number:
952-892-1695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
649 STATE ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56326-8124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-948-2219
Provider Business Practice Location Address Fax Number:
218-948-2004
Provider Enumeration Date:
09/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BLAZE
Authorized Official First Name:
CORAL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/CFO
Authorized Official Telephone Number:
952-435-7371

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  00110 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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