Basic Information
Provider Information | |||||||||
NPI: | 1689752800 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DULUTH HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUNCREST ASSISTED LIVING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 NEVADA AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | MORRIS | ||||||||
State: | MN | ||||||||
PostalCode: | 562671874 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205892004 | ||||||||
FaxNumber: | 3205892543 | ||||||||
Practice Location | |||||||||
Address1: | 2400 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 55720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188781180 | ||||||||
FaxNumber: | 2188781201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 08/03/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONCRIEF | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3205894910 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST. FRANCIS HEALTH SERVICES OF MORRIS, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 329595 | MN | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 161608100 | 05 | MN |   | MEDICAID |