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NPI Code Detail

MEDICARE: MARTIN LUTHER MANOR

MEDICARE: MARTIN LUTHER MANOR
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
1314000000XSkilled Nursing Facility331915MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
18606MAOTHERMNBLUE CROSS BLUE SHIELD
2NH0033OTHERMNUCARE
37122647OTHERMEDICA
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1750301578
Entity Type Code : Organization
Provider Name (Legal Business Name) : MARTIN LUTHER MANOR
Provider Business Mailing Address
First Line : 3530 LEXINGTON AVE N
Second Line :
City : SAINT PAUL
State : MN
Zip : 55126-8164
Country : US
Telephone Number : 651-766-4300
Fax Number : 651-766-4310
Provider Business Practice Location Address
First Line : 1401 E 100TH ST
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55425-2615
Country : US
Telephone Number : 952-888-7751
Fax Number : 952-888-5465
Authorized Official
Title or Position : CFO
Name : MR. DENNIS R JOHNSON
Credential :
Telephone Number : 651-766-4300
Provider Enumeration Date : 07/21/2006
Last Update Date : 08/22/2020

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Directions to “MARTIN LUTHER MANOR ” Practice Location

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