Provider Demographics
NPI:1558434399
Name:MSOCS-SWAN LAKE
Entity Type:Organization
Organization Name:MSOCS-SWAN LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENTIAL PROG SVCS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-582-1857
Mailing Address - Street 1:PO BOX 64979
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55164-0979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1423 SWAN LAKE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4606
Practice Address - Country:US
Practice Address - Phone:218-722-9449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities