Provider Demographics
NPI:1356589097
Name:KINGSWAY MINSITRIES, LLC
Entity type:Organization
Organization Name:KINGSWAY MINSITRIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-873-5900
Mailing Address - Street 1:815 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLE PLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:56011-1266
Mailing Address - Country:US
Mailing Address - Phone:952-873-5900
Mailing Address - Fax:
Practice Address - Street 1:815 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE PLAINE
Practice Address - State:MN
Practice Address - Zip Code:56011-1266
Practice Address - Country:US
Practice Address - Phone:952-873-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LUTHERAN HOME ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN341550310400000X
MN341708310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA537908000Medicaid