Provider Demographics
NPI:1669478129
Name:CITY OF LAKES CARE CENTER
Entity Type:Organization
Organization Name:CITY OF LAKES CARE CENTER
Other - Org Name:BENEDICTINE HEALTH CENTER OF MINNEAPOLIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOBE
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:612-879-2811
Mailing Address - Street 1:618 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1506
Mailing Address - Country:US
Mailing Address - Phone:612-879-2811
Mailing Address - Fax:612-879-2917
Practice Address - Street 1:618 E 17TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1506
Practice Address - Country:US
Practice Address - Phone:612-879-2811
Practice Address - Fax:612-879-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327352314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19667740Medicaid
MN19667740Medicaid