Provider Demographics
NPI:1093776395
Name:ST. MARKS LUTHERAN HOME
Entity Type:Organization
Organization Name:ST. MARKS LUTHERAN HOME
Other - Org Name:KENWOOD HERITAGE LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA, LALD
Authorized Official - Phone:507-434-7216
Mailing Address - Street 1:400 15TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-3232
Mailing Address - Country:US
Mailing Address - Phone:507-437-4594
Mailing Address - Fax:507-434-7201
Practice Address - Street 1:400 15TH AVE SW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-3232
Practice Address - Country:US
Practice Address - Phone:507-437-4594
Practice Address - Fax:507-434-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN329304310400000X
MN328526314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN055842700Medicaid
MN055842700Medicaid