Provider Demographics
NPI:1952623951
Name:RENVILLE HEALTH SERVICES
Entity Type:Organization
Organization Name:RENVILLE HEALTH SERVICES
Other - Org Name:MEADOWS ON MAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSIST DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-589-4902
Mailing Address - Street 1:801 NEVADA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1874
Mailing Address - Country:US
Mailing Address - Phone:320-589-2004
Mailing Address - Fax:320-589-2543
Practice Address - Street 1:609 MAIN ST S
Practice Address - Street 2:
Practice Address - City:RENVILLE
Practice Address - State:MN
Practice Address - Zip Code:56284-1814
Practice Address - Country:US
Practice Address - Phone:320-329-8381
Practice Address - Fax:320-329-3678
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. FRANCIS HEALTH SERVICES OF MORRIS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-18
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN344543310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA537682500Medicaid