Basic Information
Provider Information | |||||||||
NPI: | 1245280080 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RICE MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RICE CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1801 WILLMAR AVE SW | ||||||||
Address2: |   | ||||||||
City: | WILLMAR | ||||||||
State: | MN | ||||||||
PostalCode: | 562012882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202142700 | ||||||||
FaxNumber: | 3202142765 | ||||||||
Practice Location | |||||||||
Address1: | 1801 WILLMAR AVE SW | ||||||||
Address2: |   | ||||||||
City: | WILLMAR | ||||||||
State: | MN | ||||||||
PostalCode: | 562012882 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202142700 | ||||||||
FaxNumber: | 3202142765 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 05/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FENSKE | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3202314009 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 330432 | MN | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 585219600 | 05 | MN |   | MEDICAID | 1015450 | 01 |   | PREFERRED ONE PROVIDER | OTHER | 71-11840 | 01 |   | MEDICA PROVIDER NUMBER | OTHER | 8659CH | 01 |   | BLUE CROSS OF MINNESOTA | OTHER | NH0214 | 01 |   | UCARE PROVIDER NUMBER | OTHER |