Healthcare Provider Details

I. General information

NPI: 1801819636
Provider Name (Legal Business Name): PELICAN VALLEY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E MILL STREET
PELICAN RAPIDS MN
56572-0645
US

IV. Provider business mailing address

PO BOX 645
PELICAN RAPIDS MN
56572-0645
US

V. Phone/Fax

Practice location:
  • Phone: 218-863-2991
  • Fax: 218-863-5255
Mailing address:
  • Phone: 218-863-2911
  • Fax: 218-863-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number331787
License Number StateMN

VIII. Authorized Official

Name: MR. RICHARD KENNETH BRATLIEN
Title or Position: BOARD CHAIRPERSON
Credential:
Phone: 218-842-5106