Provider Demographics
NPI:1528384310
Name:AUGUSTANA MERCY CARE CENTER LLC
Entity Type:Organization
Organization Name:AUGUSTANA MERCY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:SEELOCHANI
Authorized Official - Middle Name:
Authorized Official - Last Name:STADTHERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-855-5041
Mailing Address - Street 1:710 S KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9405
Mailing Address - Country:US
Mailing Address - Phone:218-485-4481
Mailing Address - Fax:
Practice Address - Street 1:710 S KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9405
Practice Address - Country:US
Practice Address - Phone:218-485-4481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN349655314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN857637200Medicaid
MN857637200Medicaid