MEDICARE: ST. ANNE'S GUEST HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311Z00000X	Custodial Care Facility	8016	ND

General Provider Information

NPI Number	:	1518373224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. ANNE'S GUEST HOME

Provider Business Mailing Address
First Line	:	524 N 17TH ST
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58203-3085
Country	:	US
Telephone Number	:	701-746-9401
Fax Number	:	701-795-7825

Provider Business Practice Location Address
First Line	:	524 N 17TH ST
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58203-3085
Country	:	US
Telephone Number	:	701-746-9401
Fax Number	:	701-795-7825

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. REBECCA MARY METZGER
Credential	:
Telephone Number	:	701-746-9401

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	07/02/2014

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