1295494110 NPI number — VOP SOUTH GROVE LODGE, LLC

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 1295494110 NPI number — VOP SOUTH GROVE LODGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VOP SOUTH GROVE LODGE, 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:
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:
1295494110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5101 NE 82ND AVE STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-6343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-254-9442
Provider Business Mailing Address Fax Number:
360-254-1770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 22ND AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55912-1798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-396-4960
Provider Business Practice Location Address Fax Number:
507-434-0041
Provider Enumeration Date:
12/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
FINANCE AND LICENSING COORDINATOR
Authorized Official Telephone Number:
503-998-5810

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 404147 . This is a "MINNESOTA DEPARTMENT OF HEALTH (MDH) - ELDERLY WAIVER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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