Provider Demographics
NPI:1043251804
Name:BUFFALO LAKE HEALTHCARE CENTER INC,.
Entity Type:Organization
Organization Name:BUFFALO LAKE HEALTHCARE CENTER INC,.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-833-5364
Mailing Address - Street 1:703 W YELLOWSTONE TRL
Mailing Address - Street 2:P.O. BOX 368
Mailing Address - City:BUFFALO LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55314-1042
Mailing Address - Country:US
Mailing Address - Phone:320-833-5364
Mailing Address - Fax:320-833-5526
Practice Address - Street 1:703 W YELLOWSTONE TRL
Practice Address - Street 2:
Practice Address - City:BUFFALO LAKE
Practice Address - State:MN
Practice Address - Zip Code:55314-1042
Practice Address - Country:US
Practice Address - Phone:320-833-5364
Practice Address - Fax:320-833-5526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN550314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN550Medicaid
MN090243800Medicaid
MN8461BUOtherBLUE CROSS BLUE SHIELD
MN245589Medicare ID - Type Unspecified