1710011234 NPI number — REHOBOTH DISABLED & ELDERLY FOSTER CARE LLC

Table of content: (NPI 1710011234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710011234 NPI number — REHOBOTH DISABLED & ELDERLY FOSTER CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REHOBOTH DISABLED & ELDERLY FOSTER CARE LLC
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:
REHOBOTH L
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:
1710011234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3696 110TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORONOCO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55960-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-319-7444
Provider Business Mailing Address Fax Number:
507-367-2829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3696 110TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORONOCO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55960-2147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-319-7444
Provider Business Practice Location Address Fax Number:
507-367-2829
Provider Enumeration Date:
03/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCHRIMPF
Authorized Official First Name:
DEANN
Authorized Official Middle Name:
RUTH
Authorized Official Title or Position:
OWNER,OPERATOR AFC PROVIDER
Authorized Official Telephone Number:
507-319-7444

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  1005701-2-AFC , 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)

  • Identifier: 976472100 . This is a "ADULT FOSTER CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 702654400 . This is a "ADULT FOSTER CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 373487100 . This is a "ADULT FOSTER CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".