Provider Demographics
NPI:1982637617
Name:MIDWAY CARE CENTER INC.
Entity Type:Organization
Organization Name:MIDWAY CARE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-435-6205
Mailing Address - Street 1:114 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-1302
Mailing Address - Country:US
Mailing Address - Phone:218-435-1272
Mailing Address - Fax:218-435-6336
Practice Address - Street 1:114 2ND ST NE
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1302
Practice Address - Country:US
Practice Address - Phone:218-435-1272
Practice Address - Fax:218-435-6336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331269311Z00000X
MN331928314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN298242100Medicaid
MN7180017OtherMEDICA
MN9457MIOtherBLUE CROSS
MN9457MIOtherBLUE CROSS