Provider Demographics
NPI:1003305723
Name:PROVIDENCE VILLA
Entity Type:Organization
Organization Name:PROVIDENCE VILLA
Other - Org Name:PROVIDENCE VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HUHTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-837-9162
Mailing Address - Street 1:200 MINNESOTA AVE E
Mailing Address - Street 2:
Mailing Address - City:SEBEKA
Mailing Address - State:MN
Mailing Address - Zip Code:56477-5002
Mailing Address - Country:US
Mailing Address - Phone:218-837-9162
Mailing Address - Fax:218-837-6861
Practice Address - Street 1:200 MINNESOTA AVE E
Practice Address - Street 2:
Practice Address - City:SEBEKA
Practice Address - State:MN
Practice Address - Zip Code:56477-5002
Practice Address - Country:US
Practice Address - Phone:218-837-9162
Practice Address - Fax:218-837-6861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility