MEDICARE: SAINT THERESE OF OXBOW LAKE, LLC

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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1619236767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINT THERESE OF OXBOW LAKE, LLC

Provider Business Mailing Address
First Line	:	9751 REGENT AVE. NO.
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55443
Country	:	US
Telephone Number	:	763-493-7007
Fax Number	:

Provider Business Practice Location Address
First Line	:	9751 REGENT AVE. NO.
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55443
Country	:	US
Telephone Number	:	763-493-7007
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CAL M SHELANGOSKI
Credential	:
Telephone Number	:	952-283-2204

Provider Enumeration Date	:	05/10/2012
Last Update Date	:	11/22/2021

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