Provider Demographics
NPI:1801819636
Name:PELICAN VALLEY HEALTH CENTER
Entity Type:Organization
Organization Name:PELICAN VALLEY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIRPERSON
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:BRATLIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-842-5106
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572-0645
Mailing Address - Country:US
Mailing Address - Phone:218-863-2911
Mailing Address - Fax:218-863-5255
Practice Address - Street 1:211 E MILL STREET
Practice Address - Street 2:
Practice Address - City:PELICAN RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56572-0645
Practice Address - Country:US
Practice Address - Phone:218-863-2991
Practice Address - Fax:218-863-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331787314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7150033OtherMEDICA
ND30326Medicaid
MN537342500Medicaid
MN8979PEOtherBCBS
MNNH0312OtherUCARE
MN537342500Medicaid