Basic Information
| Provider Information | |||||||||
| NPI: | 1508814575 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHISHOLM HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205892004 | ||||||||
| FaxNumber: | 3205892543 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 6TH ST NE | ||||||||
| Address2: | |||||||||
| City: | CHISHOLM | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557191287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182545765 | ||||||||
| FaxNumber: | 2182545767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 06/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3205894902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 328696 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 140017 | 01 | FIRST PLAN | OTHER | 7122706 | 01 | MEDICA | OTHER | NH0563 | 01 | UCARE | OTHER | 936651200 | 05 | MN | MEDICAID | 9605HE | 01 | BCBS | OTHER |