Healthcare Provider Details

I. General information

NPI: 1710646641
Provider Name (Legal Business Name): BAYSIDE MANOR 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

640 3RD ST
GAYLORD MN
55334-2297
US

IV. Provider business mailing address

638 SOUTHBEND AVE
MANKATO MN
56001-2168
US

V. Phone/Fax

Practice location:
  • Phone: 507-237-2911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA LEGUM
Title or Position: MANAGER
Credential:
Phone: 507-203-1001