Healthcare Provider Details

I. General information

NPI: 1629066824
Provider Name (Legal Business Name): HALSTAD LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 4TH AVE E
HALSTAD MN
56548-4114
US

IV. Provider business mailing address

133 4TH AVE E
HALSTAD MN
56548-4114
US

V. Phone/Fax

Practice location:
  • Phone: 218-456-2105
  • Fax: 218-456-2290
Mailing address:
  • Phone: 218-456-2105
  • Fax: 218-456-2290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number328227
License Number StateMN

VIII. Authorized Official

Name: MR. DWIGHT A FUGLIE
Title or Position: EXECUTIVE DIRECTOR
Credential: LICENSED ADM.
Phone: 218-456-2105