1093775991 NPI number — BENEDICTINE CARE CENTERS

Table of content: (NPI 1093775991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093775991 NPI number — BENEDICTINE CARE CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENEDICTINE CARE CENTERS
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:
6
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:
1093775991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7700 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55807-2154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-628-9113
Provider Business Mailing Address Fax Number:
218-628-0395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55807-2154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-628-9113
Provider Business Practice Location Address Fax Number:
218-628-0395
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IKOLA
Authorized Official First Name:
DIANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
218-628-9113

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  330883 , 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: 940220900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9733LA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NH0189 . This is a "UCARE" identifier , issued by the state of ( FM ) . This identifiers is of the category "OTHER".
  • Identifier: 140015 . This is a "FIRST PLAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7111801 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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