=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407838329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAIRIE RIDGE HOSPITAL AND HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2005
-----------------------------------------------------
Last Update Date | 08/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 HWY 79E
-----------------------------------------------------
City | ELBOW LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56531-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-685-7300
-----------------------------------------------------
Fax | 218-685-7296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1411 HWY 79E
-----------------------------------------------------
City | ELBOW LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56531-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-685-7300
-----------------------------------------------------
Fax | 218-685-7296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KENT MATTSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-736-8090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | 00154
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------