Healthcare Provider Details

I. General information

NPI: 1538155809
Provider Name (Legal Business Name): DIVINE PROVIDENCE COMMUNITY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 THIRD AVE NW
SLEEPY EYE MN
56085
US

IV. Provider business mailing address

700 THIRD AVE NW
SLEEPY EYE MN
56085
US

V. Phone/Fax

Practice location:
  • Phone: 507-794-3011
  • Fax: 507-794-3020
Mailing address:
  • Phone: 507-794-3011
  • Fax: 507-794-3020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number328233
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. JAYNA MARIE GROEBNER
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 507-794-3011