Healthcare Provider Details

I. General information

NPI: 1750126397
Provider Name (Legal Business Name): SAINT THERESE OF CORCORAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19800 79TH PLACE
CORCORAN MN
55340
US

IV. Provider business mailing address

1660 HIGHWAY 100 S STE 103
SAINT LOUIS PARK MN
55416-1599
US

V. Phone/Fax

Practice location:
  • Phone: 763-567-4700
  • Fax:
Mailing address:
  • Phone: 952-283-2204
  • Fax: 952-224-0128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CAL M SHELANGOSKI
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 563-554-7606