Provider Demographics
NPI:1992861827
Name:CITY OF ULEN & MUNICIPAL LIQUOR STORE & VIKING MANOR
Entity Type:Organization
Organization Name:CITY OF ULEN & MUNICIPAL LIQUOR STORE & VIKING MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KJOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-596-8847
Mailing Address - Street 1:317 1ST STREET NW
Mailing Address - Street 2:
Mailing Address - City:ULEN
Mailing Address - State:MN
Mailing Address - Zip Code:56585
Mailing Address - Country:US
Mailing Address - Phone:218-596-8847
Mailing Address - Fax:218-596-8894
Practice Address - Street 1:317 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ULEN
Practice Address - State:MN
Practice Address - Zip Code:56585
Practice Address - Country:US
Practice Address - Phone:218-596-8847
Practice Address - Fax:218-596-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331816314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4699VIOtherBLUE CROSS BLUE SHIELD
MN7122755OtherMEDICA
MN734040100Medicaid
MN4699VIOtherBLUE CROSS BLUE SHIELD
MN7122755OtherMEDICA