Provider Demographics
NPI:1265436653
Name:DELOUGHERY HOME LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:DELOUGHERY HOME LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-483-2586
Mailing Address - Street 1:505 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:MN
Mailing Address - Zip Code:55952-1204
Mailing Address - Country:US
Mailing Address - Phone:507-523-2123
Mailing Address - Fax:507-523-3699
Practice Address - Street 1:505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:MN
Practice Address - Zip Code:55952-1204
Practice Address - Country:US
Practice Address - Phone:507-523-2123
Practice Address - Fax:507-523-3699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328692314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9138LEOtherBCBS MN
MN245311Medicare ID - Type UnspecifiedMEDICARE IDENTIFIER