Provider Demographics
NPI:1508885633
Name:GLENCOE REGIONAL HEALTH SERVICES
Entity Type:Organization
Organization Name:GLENCOE REGIONAL HEALTH SERVICES
Other - Org Name:GLENCOE REGIONAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LESKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-864-7994
Mailing Address - Street 1:1805 HENNEPIN AVE N
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-1416
Mailing Address - Country:US
Mailing Address - Phone:320-864-7716
Mailing Address - Fax:320-864-7186
Practice Address - Street 1:1805 HENNEPIN AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1416
Practice Address - Country:US
Practice Address - Phone:320-864-7716
Practice Address - Fax:320-864-7186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282NC0060X, 333600000X
MN2010013336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No333600000XSuppliersPharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN909545400Medicaid
2144023OtherPK
245263Medicare ID - Type Unspecified
MN241355Medicare ID - Type Unspecified
242355Medicare ID - Type Unspecified