Healthcare Provider Details

I. General information

NPI: 1043486210
Provider Name (Legal Business Name): CLADDAGH HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S 2ND ST
LA CRESCENT MN
55947-1372
US

IV. Provider business mailing address

10431 MOUND PRAIRIE DR
HOUSTON MN
55943-7223
US

V. Phone/Fax

Practice location:
  • Phone: 507-895-6447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. LARRY LEDEBUHR
Title or Position: PRESIDENT
Credential:
Phone: 507-896-2213