Provider Demographics
NPI:1003899402
Name:CENTRAL TODD COUNTY CARE CENTER, INC.
Entity Type:Organization
Organization Name:CENTRAL TODD COUNTY CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:E
Authorized Official - Last Name:POLOVICK
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:218-756-3636
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:406 EAST HIGHWAY 71
Mailing Address - City:CLARISSA
Mailing Address - State:MN
Mailing Address - Zip Code:56440-0038
Mailing Address - Country:US
Mailing Address - Phone:218-756-3636
Mailing Address - Fax:218-756-2276
Practice Address - Street 1:406 HIGHWAY 71 E
Practice Address - Street 2:
Practice Address - City:CLARISSA
Practice Address - State:MN
Practice Address - Zip Code:56440-2000
Practice Address - Country:US
Practice Address - Phone:218-756-3636
Practice Address - Fax:218-756-2276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN329956310400000X
MN328579314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN785540100Medicaid
MN245521Medicare ID - Type Unspecified