Healthcare Provider Details

I. General information

NPI: 1104150044
Provider Name (Legal Business Name): HERMANTOWN VALLEY ELDER CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 WAGNER RD
HERMANTOWN MN
55810-2543
US

IV. Provider business mailing address

5140 WAGNER RD
HERMANTOWN MN
55810-2543
US

V. Phone/Fax

Practice location:
  • Phone: 218-729-9831
  • Fax:
Mailing address:
  • Phone: 218-729-9831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number1031815-4-AFC
License Number StateMN

VIII. Authorized Official

Name: MR. TIMOTHY RUSSELL MAJCHRZAK SR.
Title or Position: OWNER
Credential:
Phone: 218-729-9831