Provider Demographics
NPI:1649266560
Name:ST. JOHN LUTHERAN HOME
Entity type:Organization
Organization Name:ST. JOHN LUTHERAN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-723-3200
Mailing Address - Street 1:201 S COUNTY ROAD 5
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:56087-2102
Mailing Address - Country:US
Mailing Address - Phone:507-723-3200
Mailing Address - Fax:507-723-6429
Practice Address - Street 1:201 S COUNTY ROAD 5
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MN
Practice Address - Zip Code:56087-2102
Practice Address - Country:US
Practice Address - Phone:507-723-3200
Practice Address - Fax:507-723-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328426314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8717 JOOtherBLUE CROSS PROVIDER
MNNH0374OtherSCHA - UCARE
MN346740600Medicaid
MN346740600Medicaid