Provider Demographics
NPI:1144690181
Name:GROSSKREUTZ, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GROSSKREUTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23673 291ST AVE
Mailing Address - Street 2:
Mailing Address - City:AKELEY
Mailing Address - State:MN
Mailing Address - Zip Code:56433-8049
Mailing Address - Country:US
Mailing Address - Phone:218-652-3005
Mailing Address - Fax:218-652-6316
Practice Address - Street 1:23673 291ST AVE
Practice Address - Street 2:
Practice Address - City:AKELEY
Practice Address - State:MN
Practice Address - Zip Code:56433-8049
Practice Address - Country:US
Practice Address - Phone:218-652-3005
Practice Address - Fax:218-652-6316
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1079084-1-AFC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home