Basic Information
| Provider Information | |||||||||
| NPI: | 1164473344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GGNSC ST. CHARLES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDEN LIVINGCENTER - WHITEWATER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 BLUFF AVE | ||||||||
| Address2: | |||||||||
| City: | ST CHARLES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559721325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5079323283 | ||||||||
| FaxNumber: | 5079324756 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 BLUFF AVE | ||||||||
| Address2: | |||||||||
| City: | ST CHARLES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559721325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5079323283 | ||||||||
| FaxNumber: | 5079324756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 332024 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 823957600 | 05 | MN | MEDICAID | 8R22CH | 01 | MN | BLUE CROSS MINNESOTA | OTHER | 115098 | 01 | MN | HEALTH PARTNERS MN | OTHER | NH0323 | 01 | MN | UCARE MN | OTHER | 7122532 | 01 | MN | MEDICA CHOICE | OTHER | 7100308 | 01 | MN | MEDICA SELECTCARE | OTHER |