=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063409647
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENWOOD VILLAGE CARE CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2005
-----------------------------------------------------
Last Update Date | 04/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 2ND ST SE
-----------------------------------------------------
City | GLENWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56334-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-634-5131
-----------------------------------------------------
Fax | 320-634-5777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 719 2ND ST SE
-----------------------------------------------------
City | GLENWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56334-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-634-5131
-----------------------------------------------------
Fax | 320-634-5777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MARNIE MARIE GUGISBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-763-1164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------