1295939049 NPI number — SHELL LAKE SNF 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 1295939049 NPI number — SHELL LAKE SNF LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELL LAKE SNF 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:
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:
1295939049
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 642
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUK RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56379-0642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-828-7310
Provider Business Mailing Address Fax Number:
320-764-2665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 E CTY HWY B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELL LAKE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-468-4292
Provider Business Practice Location Address Fax Number:
715-468-4232
Provider Enumeration Date:
06/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HANSEN
Authorized Official First Name:
JONATHON
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
320-828-7310

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 313M00000X , with the licence number: 2748 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2748 . This is a "BUSINESS LICENSE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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