Provider Demographics
NPI:1487640132
Name:FOUNDATION FOR RURAL HEALTH CARE
Entity Type:Organization
Organization Name:FOUNDATION FOR RURAL HEALTH CARE
Other - Org Name:CRESTVIEW MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CFO
Authorized Official - Prefix:
Authorized Official - First Name:CORAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAZE
Authorized Official - Suffix:
Authorized Official - Credentials:RN,C RAC-C
Authorized Official - Phone:952-435-7371
Mailing Address - Street 1:905 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-5405
Mailing Address - Country:US
Mailing Address - Phone:952-435-7371
Mailing Address - Fax:952-892-1695
Practice Address - Street 1:649 STATE ST NW
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:MN
Practice Address - Zip Code:56326-8124
Practice Address - Country:US
Practice Address - Phone:218-948-2219
Practice Address - Fax:218-948-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00110314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245510Medicare ID - Type UnspecifiedPROVIDER NUMBER