Basic Information
| Provider Information | |||||||||
| NPI: | 1407268642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRAIRIE PINES COMMUNITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ESSENTIA HEALTH FOSSTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 HILLIGOSS BLVD SE | ||||||||
| Address2: | |||||||||
| City: | FOSSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565421542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184351134 | ||||||||
| FaxNumber: | 7013648476 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 PRAIRE PINES DRIVE | ||||||||
| Address2: | |||||||||
| City: | FOSSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184357682 | ||||||||
| FaxNumber: | 7013648476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2014 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BODENSTEINER | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2184357633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIRST CARE MEDICAL SERVICES | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 364748 | MN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.