Healthcare Provider Details

I. General information

NPI: 1952332975
Provider Name (Legal Business Name): GOOD SHEPHERD LUTHERAN HOME OF SAUK RAPIDS, MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 4TH AVE N
SAUK RAPIDS MN
56379-2201
US

IV. Provider business mailing address

1115 4TH AVE N
SAUK RAPIDS MN
56379-2201
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-6525
  • Fax: 320-259-3463
Mailing address:
  • Phone: 320-252-6525
  • Fax: 320-259-3463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number331907
License Number StateMN

VIII. Authorized Official

Name: BRUCE ALLEN GLANZER
Title or Position: PRESIDENT CEO
Credential:
Phone: 320-252-6525