Healthcare Provider Details

I. General information

NPI: 1760667489
Provider Name (Legal Business Name): OAK TERRACE SENIOR HOUSING OF GAYLORD,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 SIBLEY AVE
GAYLORD MN
55334-2386
US

IV. Provider business mailing address

1570 TOWER BLVD
NORTH MANKATO MN
56003-2520
US

V. Phone/Fax

Practice location:
  • Phone: 507-237-2911
  • Fax: 507-237-5744
Mailing address:
  • Phone: 507-387-2037
  • Fax: 507-387-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number338323
License Number StateMN

VIII. Authorized Official

Name: MR. MICHAEL DAVID MONTAG
Title or Position: PRESIDENT
Credential:
Phone: 507-381-1312