Provider Demographics
NPI:1295494110
Name:VOP SOUTH GROVE LODGE, LLC
Entity type:Organization
Organization Name:VOP SOUTH GROVE LODGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE AND LICENSING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-998-5810
Mailing Address - Street 1:5101 NE 82ND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6343
Mailing Address - Country:US
Mailing Address - Phone:360-254-9442
Mailing Address - Fax:360-254-1770
Practice Address - Street 1:1701 22ND AVE SW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-1798
Practice Address - Country:US
Practice Address - Phone:507-396-4960
Practice Address - Fax:507-434-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN404147OtherMINNESOTA DEPARTMENT OF HEALTH (MDH) - ELDERLY WAIVER