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General NPI Number Information
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NPI Number | 1750301578
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Entity Type | Organization
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Legal Business Name | MARTIN LUTHER MANOR
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Dates
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Enumeration Date | 07/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1401 E 100TH ST
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City | BLOOMINGTON
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State | MN
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Zip | 55425-2615
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Country | US
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Telephone | 952-888-7751
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Fax | 952-888-5465
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Provider Business Mailing Address
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Address Line | 3530 LEXINGTON AVE N
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City | SAINT PAUL
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State | MN
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Zip | 55126-8164
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Country | US
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Telephone | 651-766-4300
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Fax | 651-766-4310
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Authorized Official
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Title or Position | CFO
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Name | MR. DENNIS R JOHNSON
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Credential |
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Telephone | 651-766-4300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 331915
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License Number State | MN
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