Provider Demographics
NPI:1710924428
Name:COMMUNITY MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:SUNNYSIDE HEALTHCARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BREUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-878-7621
Mailing Address - Street 1:512 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-3787
Mailing Address - Country:US
Mailing Address - Phone:218-879-4641
Mailing Address - Fax:218-879-3237
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3787
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:218-879-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN331132314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245045Medicare ID - Type Unspecified