1356321624 NPI number — ELDERS HOME INC

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 1356321624 NPI number — ELDERS HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELDERS HOME 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:
Provider Other Organization Name Type Code:
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:
1356321624
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:
PO BOX 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK MILLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-385-2005
Provider Business Mailing Address Fax Number:
218-385-4170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 S TOUSLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK MILLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-385-2005
Provider Business Practice Location Address Fax Number:
218-385-4170
Provider Enumeration Date:
01/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
CALVIN
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
218-385-2005

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  329990 , 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: 7100439 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8774EL . This is a "BCBS" identifier . This identifiers is of the category "OTHER".