Basic Information
| Provider Information | |||||||||
| NPI: | 1396748034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESSENTIA HEALTH VIRGINIA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ESSENTIA HEALTH VIRGINIA CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 9TH ST N | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187413340 | ||||||||
| FaxNumber: | 2187499427 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 9TH ST N | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187413340 | ||||||||
| FaxNumber: | 2187499427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2005 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STONE | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2187499496 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARY'S DULUTH CLINIC HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 324847 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 936325400 | 05 | MN | MEDICAID |