1730264607 NPI number — BENEDICTINE CARE CENTERS

Table of content: (NPI 1730264607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730264607 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:
1730264607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 PIONEER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED WING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55066-4217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-388-1234
Provider Business Mailing Address Fax Number:
651-388-0347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 PIONEER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED WING
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55066-3921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-388-1234
Provider Business Practice Location Address Fax Number:
651-385-5444
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOERING
Authorized Official First Name:
JAKE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR/CEO
Authorized Official Telephone Number:
651-385-3435

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  331733 , 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: 377175000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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