Provider Demographics
NPI:1598751869
Name:OUR LADY OF PEACE
Entity Type:Organization
Organization Name:OUR LADY OF PEACE
Other - Org Name:OUR LADY OF PEACE HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:STANISLAV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-789-5031
Mailing Address - Street 1:2076 ST ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5028
Mailing Address - Country:US
Mailing Address - Phone:651-789-5030
Mailing Address - Fax:651-789-0078
Practice Address - Street 1:2076 ST ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5028
Practice Address - Country:US
Practice Address - Phone:651-789-5030
Practice Address - Fax:651-789-0078
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF PEACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-22
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN248088163WH0200X
MN163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN248088Medicare Oscar/Certification