Healthcare Provider Details

I. General information

NPI: 1346245446
Provider Name (Legal Business Name): PHS MARANATHA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 69TH AVE N
BROOKLYN CENTER MN
55429-1505
US

IV. Provider business mailing address

2845 HAMLINE AVE N
ROSEVILLE MN
55113-7127
US

V. Phone/Fax

Practice location:
  • Phone: 763-549-9600
  • Fax: 763-549-9636
Mailing address:
  • Phone: 651-631-6432
  • Fax: 651-631-6122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number328432
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number328432
License Number StateMN

VIII. Authorized Official

Name: MARK MEYER
Title or Position: CFO
Credential:
Phone: 651-631-6102