Provider Demographics
NPI:1255445581
Name:DEER RIVER HEALTHCARE CENTER INC
Entity type:Organization
Organization Name:DEER RIVER HEALTHCARE CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:115 10TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-8795
Mailing Address - Country:US
Mailing Address - Phone:218-246-3012
Mailing Address - Fax:218-246-3054
Practice Address - Street 1:115 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8795
Practice Address - Country:US
Practice Address - Phone:218-246-3012
Practice Address - Fax:218-246-3054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN333483251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN983055300Medicaid
MN59-00020OtherMEDICA
MN1604ACOOtherBLUE CROSS
MN247223Medicare ID - Type Unspecified