Provider Demographics
NPI:1326196890
Name:COMMUNITY MEMORIAL HOME AT OSAKIS MINN INCORPORATED
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOME AT OSAKIS MINN INCORPORATED
Other - Org Name:GALEON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-859-2142
Mailing Address - Street 1:410 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSAKIS
Mailing Address - State:MN
Mailing Address - Zip Code:56360-8243
Mailing Address - Country:US
Mailing Address - Phone:320-859-2142
Mailing Address - Fax:320-859-6292
Practice Address - Street 1:410 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OSAKIS
Practice Address - State:MN
Practice Address - Zip Code:56360-8243
Practice Address - Country:US
Practice Address - Phone:320-859-2142
Practice Address - Fax:320-859-6292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN333635314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN030920005OtherPRIMEWEST
MNNH0438OtherU-CARE
MN668340100Medicaid
MN9755COOtherBLUE CROSS BLUE SHIELD
MN71-00435OtherMEDICA
MN030920005OtherPRIMEWEST