Provider Demographics
NPI:1508814575
Name:CHISHOLM HEALTH CENTER
Entity Type:Organization
Organization Name:CHISHOLM HEALTH CENTER
Other - Org Name:HERITAGE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-589-4902
Mailing Address - Street 1:801 NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1865
Mailing Address - Country:US
Mailing Address - Phone:320-589-2004
Mailing Address - Fax:320-589-2543
Practice Address - Street 1:321 6TH ST NE
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-1287
Practice Address - Country:US
Practice Address - Phone:218-254-5765
Practice Address - Fax:218-254-5767
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. FRANCIS HEALTH SERVICES OF MORRIS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328696314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
140017OtherFIRST PLAN
7122706OtherMEDICA
NH0563OtherUCARE
MN936651200Medicaid
9605HEOtherBCBS
MN245245BMedicare Oscar/Certification