Basic Information
| Provider Information | |||||||||
| NPI: | 1922017052 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLACIAL RIDGE HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | GLACIAL RIDGE HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10 4TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563341820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206344521 | ||||||||
| FaxNumber: | 3206342262 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 4TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563341820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206344521 | ||||||||
| FaxNumber: | 3206342262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 07/02/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STENSRUD | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3206342208 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 330414 | MN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 341-547-300 | 05 | MN | MEDICAID | 1652AGL | 01 | MN | BLUE CROSS | OTHER | 5900242 | 01 | MEDICA | OTHER |