1457548661 NPI number — KELLIHER CARE CENTER 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 1457548661 NPI number — KELLIHER CARE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLIHER CARE CENTER 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:
CORNERSTONE RESIDENCE OF KELLIHER
Provider Other Organization Name Type Code:
3
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:
1457548661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 MAIN STREET WEST
Provider Second Line Business Mailing Address:
PO BOX 189
Provider Business Mailing Address City Name:
KELLIHER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-647-8258
Provider Business Mailing Address Fax Number:
218-647-8483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 MAIN STREET WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLIHER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-647-8258
Provider Business Practice Location Address Fax Number:
218-647-8483
Provider Enumeration Date:
10/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POTVIN
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-435-6205

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  337372 , 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)





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