Healthcare Provider Details

I. General information

NPI: 1639126790
Provider Name (Legal Business Name): ECUMEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 06/03/2011
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

402 13TH AVE
TWO HARBORS MN
55616-1267
US

V. Phone/Fax

Practice location:
  • Phone: 218-834-8374
  • Fax: 218-834-8439
Mailing address:
  • Phone: 218-834-8374
  • Fax: 218-834-8439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number331615
License Number StateMN

VIII. Authorized Official

Name: MR. SCOTT RIDDLE
Title or Position: VP OF FINANCE
Credential:
Phone: 651-766-4366