Provider Demographics
NPI:1225068588
Name:ATCHISON ENTERPRISES INCORPORATED
Entity Type:Organization
Organization Name:ATCHISON ENTERPRISES INCORPORATED
Other - Org Name:SOUTH SHORE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ATCHISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-376-3175
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-0069
Mailing Address - Country:US
Mailing Address - Phone:507-376-3175
Mailing Address - Fax:507-376-9042
Practice Address - Street 1:1307 S SHORE DR
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1344
Practice Address - Country:US
Practice Address - Phone:507-376-3175
Practice Address - Fax:507-376-9042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331949314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN201042900Medicaid
MN9512LAOtherBLUE CROSS BLUE SHIELD
MN245596Medicare PIN
MN201042900Medicaid