Provider Demographics
NPI:1396807962
Name:GOOD SHEPHERD LUTHERAN HOME OF SAUK RAPIDS, MN, INC.
Entity type:Organization
Organization Name:GOOD SHEPHERD LUTHERAN HOME OF SAUK RAPIDS, MN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STORDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-252-6525
Mailing Address - Street 1:1115 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2201
Mailing Address - Country:US
Mailing Address - Phone:320-252-6525
Mailing Address - Fax:320-259-3463
Practice Address - Street 1:307 11TH ST N
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-2184
Practice Address - Country:US
Practice Address - Phone:320-252-6525
Practice Address - Fax:320-259-3463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
MN333736311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1396807962Medicaid