Provider Demographics
NPI:1063680346
Name:HIGH ISLAND CREEK RESIDENCE
Entity Type:Organization
Organization Name:HIGH ISLAND CREEK RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF BOARD
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-964-2256
Mailing Address - Street 1:708 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55307-9628
Mailing Address - Country:US
Mailing Address - Phone:507-964-5984
Mailing Address - Fax:
Practice Address - Street 1:708 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MN
Practice Address - Zip Code:55307-9628
Practice Address - Country:US
Practice Address - Phone:507-964-5984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801040315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities