=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679577118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. ANTHONY PARK HOME INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2237 COMMONWEALTH AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55108-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-646-7486
-----------------------------------------------------
Fax | 651-644-0792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2237 COMMONWEALTH AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55108-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-646-7486
-----------------------------------------------------
Fax | 651-644-0792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ADMINISTRATOR
-----------------------------------------------------
Name | MR. JOHN H BARKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-632-3503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 328423
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------