Provider Demographics
NPI:1619965365
Name:REDEEMER RESIDENCE, INC.
Entity Type:Organization
Organization Name:REDEEMER RESIDENCE, INC.
Other - Org Name:REDEEMER HEALTH AND REHAB CENTER - A MINISTRY OF ELIM CARE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE A/R MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-259-4485
Mailing Address - Street 1:625 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2922
Mailing Address - Country:US
Mailing Address - Phone:612-827-2555
Mailing Address - Fax:612-827-0450
Practice Address - Street 1:625 W 31ST ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2922
Practice Address - Country:US
Practice Address - Phone:612-827-2555
Practice Address - Fax:612-827-0450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327804314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN599340700Medicaid
MN327804OtherMINNESOTA STATE LICENSE