Basic Information
| Provider Information | |||||||||
| NPI: | 1609233980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KOOCHICHING HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LITTLEFORK CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 NEVADA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205892004 | ||||||||
| FaxNumber: | 3205892543 | ||||||||
| Practice Location | |||||||||
| Address1: | 912 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LITTLEFORK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566539357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182786634 | ||||||||
| FaxNumber: | 2182786637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 01/18/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3205894919 | ||||||||
| 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 | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.