Provider Demographics
NPI:1225049018
Name:DEER RIVER HEALTHCARE CENTER, INC.
Entity Type:Organization
Organization Name:DEER RIVER HEALTHCARE CENTER, INC.
Other - Org Name:ESSENTIA HEALTH DEER RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:115 10TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-8795
Mailing Address - Country:US
Mailing Address - Phone:218-246-2900
Mailing Address - Fax:218-246-3013
Practice Address - Street 1:115 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8795
Practice Address - Country:US
Practice Address - Phone:218-246-2900
Practice Address - Fax:218-246-3013
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN800862-1-ADC261QA0600X
MN331194282NC0060X
MN333123310400000X
332B00000X, 3416L0300X, 347B00000X
MN204876-9333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3416L0300XTransportation ServicesAmbulanceLand Transport
No347B00000XTransportation ServicesBus
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5025365OtherMEDICA
MN1604HCOOtherBLUE CROSS
MN1021626OtherPREFERRED ONE
MN1225049018Medicaid
MN300367OtherUCARE
MNC06025Medicare PIN
MN300367OtherUCARE
MN1225049018Medicaid