Basic Information
| Provider Information | |||||||||
| NPI: | 1851516389 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEER RIVER HEALTHCARE CENTER INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY MEMORIAL HOSPITAL OF DEER RIVER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 10TH AVENUE NE | ||||||||
| Address2: | |||||||||
| City: | DEER RIVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566369700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182462900 | ||||||||
| FaxNumber: | 2182463013 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 10TH AVENUE NE | ||||||||
| Address2: | |||||||||
| City: | DEER RIVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566369700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182462900 | ||||||||
| FaxNumber: | 2182463013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOOS | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2182463047 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEER RIVER HEALTHCARE CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1604HCO | 01 | MN | BLUE CROSS | OTHER | 300367 | 01 | MN | UCARE | OTHER | 5025365 | 01 | MN | MEDICA | OTHER | 618245300 | 05 | MN | MEDICAID | 1021626 | 01 | MN | PREFERRED ONE | OTHER |