Provider Demographics
NPI:1932280120
Name:PENNINGTON HEALTH SERVICES
Entity Type:Organization
Organization Name:PENNINGTON HEALTH SERVICES
Other - Org Name:THIEF RIVER CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-589-4902
Mailing Address - Street 1:801 NEVADA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1874
Mailing Address - Country:US
Mailing Address - Phone:320-589-4902
Mailing Address - Fax:320-589-2543
Practice Address - Street 1:130 LABREE AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701
Practice Address - Country:US
Practice Address - Phone:320-589-4902
Practice Address - Fax:320-589-2543
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. FRANCIS HEALTH SERVICES OF MORRIS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-17
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN591605000Medicaid
MN245252Medicare Oscar/Certification