Provider Demographics
NPI:1629055231
Name:INTER-FAITH CARE CENTER
Entity Type:Organization
Organization Name:INTER-FAITH CARE CENTER
Other - Org Name:CARLTON PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PENK
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:218-384-8411
Mailing Address - Street 1:813 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:MN
Mailing Address - Zip Code:55718-9201
Mailing Address - Country:US
Mailing Address - Phone:218-384-8440
Mailing Address - Fax:218-384-8442
Practice Address - Street 1:813 3RD ST
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:MN
Practice Address - Zip Code:55718-9201
Practice Address - Country:US
Practice Address - Phone:218-384-8440
Practice Address - Fax:218-384-8442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328357310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN090963700Medicaid