Provider Demographics
NPI:1770560005
Name:SHOLOM HOME WEST INC
Entity type:Organization
Organization Name:SHOLOM HOME WEST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WYCKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-939-1637
Mailing Address - Street 1:3620 PHILLIPS PKWY
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3700
Mailing Address - Country:US
Mailing Address - Phone:952-935-6311
Mailing Address - Fax:952-935-2701
Practice Address - Street 1:3620 PHILLIPS PKWY
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3700
Practice Address - Country:US
Practice Address - Phone:952-935-6311
Practice Address - Fax:952-935-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328688314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN23377OtherHEALTH PARTNERS
MN4553SHOtherBLUE CROSS OF MINNESOTA
MN971216005OtherMETRA HEALTH
MN151743100Medicaid
MNNH0048OtherUCARE
000320420OtherHIGHMARK
ND30425Medicaid
MN7100366OtherEVERCARE
MN7122633OtherMEDICA