Healthcare Provider Details

I. General information

NPI: 1750388336
Provider Name (Legal Business Name): GAYLORD LAKEVIEW HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 3RD ST
GAYLORD MN
55334-2297
US

IV. Provider business mailing address

640 3RD ST
GAYLORD MN
55334-2297
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number318160
License Number StateMN

VIII. Authorized Official

Name: MARY NELL ZELLNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 507-237-2911