=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295060077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN MINN. HOMECARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2009
-----------------------------------------------------
Last Update Date | 07/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213 PARKWAY AVE
-----------------------------------------------------
City | EAGLE LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56024-7709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-257-2252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 375 PO BOX 375
-----------------------------------------------------
City | EAGLE LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56024-0375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-257-2252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS BARBARA JANE SONTAG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-257-2252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 346457
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------