Provider Demographics
NPI:1700115003
Name:MCCORNELL COURT
Entity Type:Organization
Organization Name:MCCORNELL COURT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-338-4671
Mailing Address - Street 1:P.O. BOX 30
Mailing Address - Street 2:
Mailing Address - City:PARKERS PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56361
Mailing Address - Country:US
Mailing Address - Phone:218-338-4671
Mailing Address - Fax:218-338-5917
Practice Address - Street 1:122 NO. MCCORNELL AVENUE
Practice Address - Street 2:
Practice Address - City:PARKERS PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56361
Practice Address - Country:US
Practice Address - Phone:218-338-4671
Practice Address - Fax:218-338-5917
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. WILLIAMS LIVING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-15
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN346068310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN887342900Medicaid
245588Medicare UPIN