Provider Demographics
NPI:1538155809
Name:DIVINE PROVIDENCE COMMUNITY HOME
Entity type:Organization
Organization Name:DIVINE PROVIDENCE COMMUNITY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GROEBNER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:507-794-3011
Mailing Address - Street 1:700 THIRD AVE NW
Mailing Address - Street 2:
Mailing Address - City:SLEEPY EYE
Mailing Address - State:MN
Mailing Address - Zip Code:56085
Mailing Address - Country:US
Mailing Address - Phone:507-794-3011
Mailing Address - Fax:507-794-3020
Practice Address - Street 1:700 THIRD AVE NW
Practice Address - Street 2:
Practice Address - City:SLEEPY EYE
Practice Address - State:MN
Practice Address - Zip Code:56085
Practice Address - Country:US
Practice Address - Phone:507-794-3011
Practice Address - Fax:507-794-3020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328233314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN356540800Medicaid
MN356540800Medicaid
MN245599Medicare Oscar/Certification