=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811997489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARROAD CARE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2005
-----------------------------------------------------
Last Update Date | 02/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 LAKE ST NW
-----------------------------------------------------
City | WARROAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56763-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-386-1235
-----------------------------------------------------
Fax | 218-386-3548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 LAKE ST NW
-----------------------------------------------------
City | WARROAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56763-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-386-1235
-----------------------------------------------------
Fax | 218-386-3548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MARK BERTILRUD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-386-1235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------