Basic Information
| Provider Information | |||||||||
| NPI: | 1811985286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RENVILLE HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RENVILLE HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 NEVADA AVENUE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205892004 | ||||||||
| FaxNumber: | 3205892543 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 SE ELM ST | ||||||||
| Address2: | |||||||||
| City: | RENVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562841815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3203298381 | ||||||||
| FaxNumber: | 3203293678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| 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 | 310400000X | 330050 | MN | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 314000000X | 329011 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 03080200801 | 01 | MN | PRIME WEST | OTHER | 330050 | 01 | MN | ASSISTED LIVING - MEDICAI | OTHER | 792697900 | 05 | MN | MEDICAID |