Healthcare Provider Details

I. General information

NPI: 1336209139
Provider Name (Legal Business Name): FAIRVIEW NORTHLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 NORTHLAND DR
PRINCETON MN
55371-2172
US

IV. Provider business mailing address

13854 RIVERVIEW DR NW
ELK RIVER MN
55330-1626
US

V. Phone/Fax

Practice location:
  • Phone: 763-389-6420
  • Fax:
Mailing address:
  • Phone: 763-441-0487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number4410
License Number StateMN

VIII. Authorized Official

Name: SANDRA WHITCOMB
Title or Position: REHAB ASSISTANT
Credential:
Phone: 763-389-6420