Healthcare Provider Details

I. General information

NPI: 1598751869
Provider Name (Legal Business Name): OUR LADY OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 ST ANTHONY AVE
ST PAUL MN
55104-5028
US

IV. Provider business mailing address

2076 ST ANTHONY AVE
ST PAUL MN
55104-5028
US

V. Phone/Fax

Practice location:
  • Phone: 651-789-5030
  • Fax: 651-789-0078
Mailing address:
  • Phone: 651-789-5030
  • Fax: 651-789-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number248088
License Number StateMN

VIII. Authorized Official

Name: JEFFREY THORNE
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 651-789-5031