Healthcare Provider Details

I. General information

NPI: 1750301578
Provider Name (Legal Business Name): MARTIN LUTHER MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 100TH ST
BLOOMINGTON MN
55425-2615
US

IV. Provider business mailing address

3530 LEXINGTON AVE N
SAINT PAUL MN
55126-8164
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-7751
  • Fax: 952-888-5465
Mailing address:
  • Phone: 651-766-4300
  • Fax: 651-766-4310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number331915
License Number StateMN

VIII. Authorized Official

Name: MR. DENNIS R JOHNSON
Title or Position: CFO
Credential:
Phone: 651-766-4300