Provider Demographics
NPI:1629066824
Name:HALSTAD LIVING CENTER
Entity Type:Organization
Organization Name:HALSTAD LIVING CENTER
Other - Org Name:HALSTAD LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:A
Authorized Official - Last Name:FUGLIE
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED ADM
Authorized Official - Phone:218-456-2105
Mailing Address - Street 1:133 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:HALSTAD
Mailing Address - State:MN
Mailing Address - Zip Code:56548-4114
Mailing Address - Country:US
Mailing Address - Phone:218-456-2105
Mailing Address - Fax:218-456-2290
Practice Address - Street 1:133 4TH AVE E
Practice Address - Street 2:
Practice Address - City:HALSTAD
Practice Address - State:MN
Practice Address - Zip Code:56548-4114
Practice Address - Country:US
Practice Address - Phone:218-456-2105
Practice Address - Fax:218-456-2290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN HOMES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-11
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328227314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN075740300Medicaid
MN7122758OtherMEDICA INSURANCVE
ND23605OtherND BLUE CROSS AND BLUE SH
ND30280Medicaid
MN9506 HAOtherMN BC-BS
ND30280Medicaid