Provider Demographics
NPI:1588807572
Name:CEDAR CREST OF HUTCHINSON
Entity Type:Organization
Organization Name:CEDAR CREST OF HUTCHINSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:EWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-587-7077
Mailing Address - Street 1:225 SHADY RIDGE RD NW
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-1407
Mailing Address - Country:US
Mailing Address - Phone:320-587-7077
Mailing Address - Fax:320-587-4299
Practice Address - Street 1:225 SHADY RIDGE RD NW
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-1407
Practice Address - Country:US
Practice Address - Phone:320-587-7077
Practice Address - Fax:320-587-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNFBL-6056-4162310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA163317100Medicaid