Basic Information
Provider Information | |||||||||
NPI: | 1508950775 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANFORD HEALTH NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SANFORD CANBY MEDICAL CENTER-HOME CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5074 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053286585 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 213 SAINT OLAF AVE N STE B | ||||||||
Address2: |   | ||||||||
City: | CANBY | ||||||||
State: | MN | ||||||||
PostalCode: | 562201308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5072237277 | ||||||||
FaxNumber: | 5072235346 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 11/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRISON | ||||||||
AuthorizedOfficialFirstName: | TONY | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 6053288380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SANFORD HEALTH NETWORK | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X |   |   | N |   | Respite Care Facility | Respite Care |   | 251E00000X | 331442 | MN | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 01015433 | 01 |   | PREFERRED ONE | OTHER | 660253300 | 05 | MN |   | MEDICAID | 125921 | 01 |   | UCARE | OTHER | 1599ACA | 01 |   | BLUE CROSS | OTHER |