Provider Demographics
NPI:1407303662
Name:REISCH, ROBERT ALLEN
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:REISCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LEEANNE
Other - Last Name:REISCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19758 DAYTON HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-7621
Mailing Address - Country:US
Mailing Address - Phone:218-340-1359
Mailing Address - Fax:218-737-0028
Practice Address - Street 1:19758 DAYTON HOLLOW LN
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-7621
Practice Address - Country:US
Practice Address - Phone:218-340-1359
Practice Address - Fax:218-737-0028
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNAPPLIED311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home