Provider Demographics
NPI:1891798823
Name:MONTICELLO BIG LAKE HOSPITAL NURSING HOME
Entity Type:Organization
Organization Name:MONTICELLO BIG LAKE HOSPITAL NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAWELK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-271-2306
Mailing Address - Street 1:1013 HART BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8575
Mailing Address - Country:US
Mailing Address - Phone:763-295-2945
Mailing Address - Fax:763-271-2421
Practice Address - Street 1:1013 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8575
Practice Address - Country:US
Practice Address - Phone:763-295-2945
Practice Address - Fax:763-271-2421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328129282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24Z362Medicare Oscar/Certification
MN245511Medicare ID - Type UnspecifiedMEDICARE PROVIDER N.H.
MN240094Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MN241362Medicare Oscar/Certification