Basic Information
Provider Information | |||||||||
NPI: | 1114094620 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTHPARTNERS RC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RENVILLE COUNTY HOSPICE | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 HEALTHY WAY | ||||||||
Address2: |   | ||||||||
City: | OLIVIA | ||||||||
State: | MN | ||||||||
PostalCode: | 562771117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205231261 | ||||||||
FaxNumber: | 3205238349 | ||||||||
Practice Location | |||||||||
Address1: | 100 HEALTHY WAY | ||||||||
Address2: |   | ||||||||
City: | OLIVIA | ||||||||
State: | MN | ||||||||
PostalCode: | 562771117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205231261 | ||||||||
FaxNumber: | 3205233458 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2006 | ||||||||
LastUpdateDate: | 05/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLAD | ||||||||
AuthorizedOfficialFirstName: | NATHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3205233575 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HEALTHPARTNERS RC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | 331046 | MN | N |   | Nursing & Custodial Care Facilities | Hospice, Inpatient |   | 251G00000X | 331046 | MN | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 304706539 | 05 | MI |   | MEDICAID | 072262101 | 05 | TX |   | MEDICAID | 502347500 | 05 | MN |   | MEDICAID | 2457 | 05 | ND |   | MEDICAID | 404706548 | 05 | MI |   | MEDICAID | 5529420 | 05 | SD |   | MEDICAID | H4160068805 | 05 | OK |   | MEDICAID | 268517500 | 05 | MN |   | MEDICAID | 80617900 | 05 | WI |   | MEDICAID |