Healthcare Provider Details

I. General information

NPI: 1316155237
Provider Name (Legal Business Name): OPPORTUNITY MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 13TH AVE SE
SAINT CLOUD MN
56304-1913
US

IV. Provider business mailing address

1908 KRUCHTEN CT S PO BOX 280
SARTELL MN
56377-4645
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-0135
  • Fax: 320-240-8527
Mailing address:
  • Phone: 320-240-1900
  • Fax: 320-240-8527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number801815-3-RS
License Number StateMN

VIII. Authorized Official

Name: REGAN STOMMES
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 320-240-1900