Healthcare Provider Details

I. General information

NPI: 1750946539
Provider Name (Legal Business Name): THE WATERVIEW SHORES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 13TH AVE
TWO HARBORS MN
55616-1267
US

IV. Provider business mailing address

638 SOUTHBEND AVE
MANKATO MN
56001-2168
US

V. Phone/Fax

Practice location:
  • Phone: 218-834-0849
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JOSH LEGUM
Title or Position: CEO
Credential:
Phone: 507-203-1001