MEDICARE: PHS MARANATHA INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	328432	MN
2	314000000X	Skilled Nursing Facility	328432	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	NH0032	OTHER	MN	UCARE

General Provider Information

NPI Number	:	1346245446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHS MARANATHA INC.

Provider Business Mailing Address
First Line	:	2845 HAMLINE AVE N
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-7127
Country	:	US
Telephone Number	:	651-631-6432
Fax Number	:	651-631-6122

Provider Business Practice Location Address
First Line	:	5409 69TH AVE N
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-1505
Country	:	US
Telephone Number	:	763-549-9600
Fax Number	:	763-549-9636

Authorized Official
Title or Position	:	CFO
Name	:	MARK MEYER
Credential	:
Telephone Number	:	651-631-6102

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	11/11/2025

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Directions to “PHS MARANATHA INC. ” Practice Location

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