=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215088521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ECUMEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 05/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 MADISON AVE
-----------------------------------------------------
City | DETROIT LAKES
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56501-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-847-4486
-----------------------------------------------------
Fax | 218-847-4488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3530 LEXINGTON AVE N
-----------------------------------------------------
City | SHOREVIEW
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55126-8166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-766-4300
-----------------------------------------------------
Fax | 651-766-4479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF FINANCE
-----------------------------------------------------
Name | MR. SCOTT BJERKEVEDT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-766-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------