Provider Demographics
NPI:1710970942
Name:FARIBAULT HEALTH CARE LLC
Entity Type:Organization
Organization Name:FARIBAULT HEALTH CARE LLC
Other - Org Name:ST LUCAS CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MOLGARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCNHA
Authorized Official - Phone:507-332-5100
Mailing Address - Street 1:500 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-6346
Mailing Address - Country:US
Mailing Address - Phone:507-332-5100
Mailing Address - Fax:507-332-5188
Practice Address - Street 1:500 1ST ST SE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6346
Practice Address - Country:US
Practice Address - Phone:507-332-5100
Practice Address - Fax:507-332-5188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN329214310400000X
MN329250314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN470618800Medicaid
MN245067Medicare Oscar/Certification
MN470618800Medicaid
MN4292190001Medicare NSC