Provider Demographics
NPI:1114185436
Name:ST. THERESE AT OXBOW LAKE
Entity Type:Organization
Organization Name:ST. THERESE AT OXBOW LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAMPUS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DINAH
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-493-7007
Mailing Address - Street 1:5200 OAK GROVE PKWY N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-4031
Mailing Address - Country:US
Mailing Address - Phone:763-493-7000
Mailing Address - Fax:763-493-7001
Practice Address - Street 1:5200 OAK GROVE PKWY N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-4031
Practice Address - Country:US
Practice Address - Phone:763-493-7000
Practice Address - Fax:763-493-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN339337310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility