Healthcare Provider Details

I. General information

NPI: 1912071630
Provider Name (Legal Business Name): PHS/CAMBRIDGE CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date: 01/29/2007
Reactivation Date: 03/20/2007

III. Provider practice location address

548 1ST AVE W
CAMBRIDGE MN
55008-1020
US

IV. Provider business mailing address

548 1ST AVE W
CAMBRIDGE MN
55008-1020
US

V. Phone/Fax

Practice location:
  • Phone: 763-689-2323
  • Fax:
Mailing address:
  • Phone: 763-231-0410
  • Fax: 763-231-0420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number342879
License Number StateMN

VIII. Authorized Official

Name: MR. MARK MEYER
Title or Position: CFO
Credential:
Phone: 651-631-6120