Healthcare Provider Details

I. General information

NPI: 1457788994
Provider Name (Legal Business Name): CENTRACARE HEALTH-PAYNESVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WASHBURNE AVE
PAYNESVILLE MN
56362-1658
US

IV. Provider business mailing address

200 W 1ST ST
PAYNESVILLE MN
56362-1445
US

V. Phone/Fax

Practice location:
  • Phone: 320-243-7451
  • Fax:
Mailing address:
  • Phone: 320-243-3767
  • Fax: 320-243-7955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL A. BLAIR
Title or Position: SR. VICE PRESIDENT AND CFO
Credential:
Phone: 320-255-5665