Provider Demographics
NPI:1710352869
Name:OUR LADY OF PEACE
Entity Type:Organization
Organization Name:OUR LADY OF PEACE
Other - Org Name:OUR LADY OF PEACE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
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 SAINT ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2076 SAINT ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4543
Practice Address - Country:US
Practice Address - Phone:651-789-5031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN375345315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN241573Medicare Oscar/Certification