Provider Demographics
NPI:1497755185
Name:LUTHER MEMORIAL HOME
Entity Type:Organization
Organization Name:LUTHER MEMORIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-786-3401
Mailing Address - Street 1:750 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:ND
Mailing Address - Zip Code:58257-1606
Mailing Address - Country:US
Mailing Address - Phone:701-786-3401
Mailing Address - Fax:701-786-9022
Practice Address - Street 1:750 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:ND
Practice Address - Zip Code:58257-1606
Practice Address - Country:US
Practice Address - Phone:701-786-3401
Practice Address - Fax:701-786-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND027310400000X
NDAL23310400000X
ND1039A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30024Medicaid
MN3050271 00Medicaid
ND001115OtherND BLUE CROSS BLUE SHIELD
MN9846LUOtherMN BLUE CROSS BLUE SHIELD
ND355040Medicare ID - Type Unspecified
MN3050271 00Medicaid