Healthcare Provider Details

I. General information

NPI: 1922767847
Provider Name (Legal Business Name): VOP DULUTH HEIGHTS LODGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 MAPLE GROVE RD
DULUTH MN
55811-4521
US

IV. Provider business mailing address

5101 NE 82ND AVE STE 200
VANCOUVER WA
98662-6343
US

V. Phone/Fax

Practice location:
  • Phone: 218-461-4288
  • Fax: 218-722-3760
Mailing address:
  • Phone: 360-254-9442
  • Fax: 360-254-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. TERRI LYNN BAKER
Title or Position: FINANCE AND LICENSING COORDINATOR
Credential:
Phone: 503-998-5810