1568752533 NPI number — RUM RIVER HEALTH SERVICES, INC.

Table of content: (NPI 1568752533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568752533 NPI number — RUM RIVER HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUM RIVER HEALTH SERVICES, INC.
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:
MEN'S RESIDENCE
Provider Other Organization Name Type Code:
5
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:
1568752533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 18TH AVENUE NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55371-4756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-389-5080
Provider Business Mailing Address Fax Number:
763-631-9117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3079 90TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCETON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-389-5080
Provider Business Practice Location Address Fax Number:
763-631-9117
Provider Enumeration Date:
04/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LARSON
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
763-389-5080

Provider Taxonomy Codes

  • Taxonomy code: 276400000X , with the licence number:  FBL-4868-25062 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 324500000X , with the licence number: FBL-4868-25062 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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