Healthcare Provider Details

I. General information

NPI: 1487640132
Provider Name (Legal Business Name): FOUNDATION FOR RURAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 STATE ST NW
EVANSVILLE MN
56326-8124
US

IV. Provider business mailing address

905 W 155TH ST
BURNSVILLE MN
55306-5405
US

V. Phone/Fax

Practice location:
  • Phone: 218-948-2219
  • Fax: 218-948-2004
Mailing address:
  • Phone: 952-435-7371
  • Fax: 952-892-1695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number00110
License Number StateMN

VIII. Authorized Official

Name: CORAL BLAZE
Title or Position: CEO/CFO
Credential: RN,C RAC-C
Phone: 952-435-7371