Provider Demographics
NPI:1073788311
Name:HILLCREST SENIOR LIVING
Entity Type:Organization
Organization Name:HILLCREST SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-253-2157
Mailing Address - Street 1:311 BROADWAY AVE NE
Mailing Address - Street 2:
Mailing Address - City:RED LAKE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56750
Mailing Address - Country:US
Mailing Address - Phone:218-253-2157
Mailing Address - Fax:218-253-4676
Practice Address - Street 1:311 BROADWAY AVE NE
Practice Address - Street 2:
Practice Address - City:RED LAKE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56750
Practice Address - Country:US
Practice Address - Phone:218-253-2157
Practice Address - Fax:218-253-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN340194314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
9839HIOtherBCBS MN
MN257150000Medicaid
245614Medicare Oscar/Certification