Basic Information
| Provider Information | |||||||||
| NPI: | 1609989326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEER RIVER HEALTHCARE CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ESSENTIA HEALTH HOMESTEAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 115 10TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | DEER RIVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566368795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182462900 | ||||||||
| FaxNumber: | 2182463013 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 10TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | DEER RIVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566368795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182462900 | ||||||||
| FaxNumber: | 2182463057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOREN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2187861009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARY'S DULUTH CLINIC HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 331919 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5025365 | 01 | MN | MEDICA | OTHER | 1609989326 | 05 | MN | MEDICAID | 1604E | 01 | MN | BLUE CROSS | OTHER | 1021626 | 01 | MN | PREFERRED ONE | OTHER | 300367 | 01 | MN | UCARE | OTHER |