Provider Demographics
NPI:1477660777
Name:BOUNDARY WATERS CARE CENTER
Entity Type:Organization
Organization Name:BOUNDARY WATERS CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-365-8044
Mailing Address - Street 1:200 W CONAN ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1143
Mailing Address - Country:US
Mailing Address - Phone:218-365-8044
Mailing Address - Fax:218-365-8734
Practice Address - Street 1:200 W CONAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1143
Practice Address - Country:US
Practice Address - Phone:218-365-8044
Practice Address - Fax:218-365-8734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN355431314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
245138Medicare Oscar/Certification