Healthcare Provider Details

I. General information

NPI: 1992861827
Provider Name (Legal Business Name): CITY OF ULEN & MUNICIPAL LIQUOR STORE & VIKING MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 1ST ST NW
ULEN MN
56585
US

IV. Provider business mailing address

317 1ST STREET NW
ULEN MN
56585
US

V. Phone/Fax

Practice location:
  • Phone: 218-596-8847
  • Fax: 218-596-8894
Mailing address:
  • Phone: 218-596-8847
  • Fax: 218-596-8894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number331816
License Number StateMN

VIII. Authorized Official

Name: MR. TODD M KJOS
Title or Position: ADMINISTRATOR
Credential:
Phone: 218-596-8847