Provider Demographics
NPI:1134125644
Name:INTER-FAITH CARE CENTER
Entity Type:Organization
Organization Name:INTER-FAITH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PENK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-384-8411
Mailing Address - Street 1:811 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:MN
Mailing Address - Zip Code:55718-9228
Mailing Address - Country:US
Mailing Address - Phone:218-384-4258
Mailing Address - Fax:218-384-9820
Practice Address - Street 1:811 3RD ST
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:MN
Practice Address - Zip Code:55718-9228
Practice Address - Country:US
Practice Address - Phone:218-384-4258
Practice Address - Fax:218-384-9820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328756314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9753CAOtherBLUE CROSS & BLUE SHIELD
MN245024Medicare ID - Type Unspecified