Provider Demographics
NPI:1417950593
Name:VILLAGE OF FERTILE
Entity Type:Organization
Organization Name:VILLAGE OF FERTILE
Other - Org Name:FAIR MEADOW NURSING HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CITY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:LIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-945-6194
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:300 GARFIELD AVE. SE
Mailing Address - City:FERTILE
Mailing Address - State:MN
Mailing Address - Zip Code:56540-0008
Mailing Address - Country:US
Mailing Address - Phone:218-945-6194
Mailing Address - Fax:218-945-6459
Practice Address - Street 1:300 GARFIELD AVE. SE
Practice Address - Street 2:
Practice Address - City:FERTILE
Practice Address - State:MN
Practice Address - Zip Code:56540-0008
Practice Address - Country:US
Practice Address - Phone:218-945-6194
Practice Address - Fax:218-945-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327713314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN804740500Medicaid
MN4541FAOtherBLUE CROSS/BLUE SHIELD
MN245545Medicare ID - Type Unspecified