1417950593 NPI number — VILLAGE OF FERTILE

Table of content: (NPI 1417950593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417950593 NPI number — VILLAGE OF FERTILE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE OF FERTILE
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:
FAIR MEADOW NURSING HOME
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:
1417950593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8
Provider Second Line Business Mailing Address:
300 GARFIELD AVE. SE
Provider Business Mailing Address City Name:
FERTILE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56540-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-945-6194
Provider Business Mailing Address Fax Number:
218-945-6459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 GARFIELD AVE. SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERTILE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56540-0008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-945-6194
Provider Business Practice Location Address Fax Number:
218-945-6459
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBERTSON
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
218-945-6194

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  327713 , 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: 804740500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4541FA . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".