Basic Information
| Provider Information | |||||||||
| NPI: | 1386638179 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUTHERAN CHARITY ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JAMESTOWN REGIONAL MEDICAL CENTER HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2422 20TH ST SW | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584016201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Practice Location | |||||||||
| Address1: | 2422 20TH ST SW | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584016201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DELFS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7019524850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 6014A | ND | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 1452294 | 05 | ND | MEDICAID |