MEDICARE: ESSENTIA HEALTH VIRGINIA, LLC

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	314000000X	Skilled Nursing Facility	324847	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

General Provider Information

NPI Number	:	1396748034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESSENTIA HEALTH VIRGINIA, LLC

Provider Business Mailing Address
First Line	:	901 9TH ST N
Second Line	:
City	:	VIRGINIA
State	:	MN
Zip	:	55792-2348
Country	:	US
Telephone Number	:	218-741-3340
Fax Number	:	218-749-9427

Provider Business Practice Location Address
First Line	:	901 9TH ST N
Second Line	:
City	:	VIRGINIA
State	:	MN
Zip	:	55792-2348
Country	:	US
Telephone Number	:	218-741-3340
Fax Number	:	218-749-9427

Authorized Official
Title or Position	:	COO
Name	:	SAMUEL STONE
Credential	:
Telephone Number	:	218-749-9496

Provider Enumeration Date	:	05/26/2005
Last Update Date	:	04/07/2022

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