Basic Information
| Provider Information | |||||||||
| NPI: | 1932150125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GGNSC LA CRESCENT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDEN LIVINGCENTER - LA CRESCENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S HILL ST | ||||||||
| Address2: | |||||||||
| City: | LA CRESCENT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559471389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078954445 | ||||||||
| FaxNumber: | 5078956461 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S HILL ST | ||||||||
| Address2: | |||||||||
| City: | LA CRESCENT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559471389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078954445 | ||||||||
| FaxNumber: | 5078956461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 332019 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 115206 | 01 | MN | HEALTH PARTNERS MN | OTHER | 245319 | 01 | MN | SECURITY HEALTH PLAN | OTHER | 7122513 | 01 | MN | MEDICA CHOICE | OTHER | 8R72LA | 01 | MN | BLUE CROSS MINNESOTA | OTHER | 486728900 | 05 | MN | MEDICAID | 7100285 | 01 | MN | MEDICA SELECTCARE | OTHER | 03062700301 | 01 | MN | PRIMEWEST | OTHER | NH0239 | 01 | MN | UCARE MN | OTHER |