1154311280 NPI number — CERENITY SENIOR CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154311280 NPI number — CERENITY SENIOR CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CERENITY SENIOR 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:
CERENITY CARE CENTER ON HUMBOLDT
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:
1154311280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 HUMBOLDT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55107-4001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-220-1740
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 HUMBOLDT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55107-4001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-220-1740
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BERGIEN
Authorized Official First Name:
TRICIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR, REIMBURSEMENT
Authorized Official Telephone Number:
612-991-6519

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  245255 , 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: 044518500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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