Provider Demographics
NPI:1326162413
Name:ECUMEN
Entity Type:Organization
Organization Name:ECUMEN
Other - Org Name:ECUMEN LAKESHORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-766-4300
Mailing Address - Street 1:4002 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-2243
Mailing Address - Country:US
Mailing Address - Phone:218-625-7825
Mailing Address - Fax:
Practice Address - Street 1:4002 LONDON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-2243
Practice Address - Country:US
Practice Address - Phone:218-625-7825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332007314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8614LAOtherBCBS
7122649OtherMEDICA
MN001043000Medicaid
NH0212OtherUCARE
245215Medicare ID - Type UnspecifiedMEDICARE