Healthcare Provider Details

I. General information

NPI: 1215932728
Provider Name (Legal Business Name): VILLA ST. VINCENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 WALSH ST
CROOKSTON MN
56716
US

IV. Provider business mailing address

516 WALSH ST
CROOKSTON MN
56716
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-3424
  • Fax: 218-281-4755
Mailing address:
  • Phone: 218-281-3424
  • Fax: 218-281-4755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number325662
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number353890
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number328575
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number352789
License Number StateMN

VIII. Authorized Official

Name: JUDY HULST
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 218-281-9700