Provider Demographics
NPI:1538292156
Name:ST. WILLIAM'S LIVING CENTER
Entity Type:Organization
Organization Name:ST. WILLIAM'S LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-338-1001
Mailing Address - Street 1:212 W SOO ST
Mailing Address - Street 2:
Mailing Address - City:PARKERS PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56361-4404
Mailing Address - Country:US
Mailing Address - Phone:218-338-4671
Mailing Address - Fax:218-338-5917
Practice Address - Street 1:212 W SOO ST
Practice Address - Street 2:
Practice Address - City:PARKERS PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56361-4404
Practice Address - Country:US
Practice Address - Phone:218-338-4671
Practice Address - Fax:218-338-5917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN335483314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN887342900Medicaid
MN245588Medicare ID - Type UnspecifiedLTC