Provider Demographics
NPI:1730264607
Name:BENEDICTINE CARE CENTERS
Entity type:Organization
Organization Name:BENEDICTINE CARE CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOERING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-385-3435
Mailing Address - Street 1:135 PIONEER RD
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-4217
Mailing Address - Country:US
Mailing Address - Phone:651-388-1234
Mailing Address - Fax:651-388-0347
Practice Address - Street 1:213 PIONEER RD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-3921
Practice Address - Country:US
Practice Address - Phone:651-388-1234
Practice Address - Fax:651-385-5444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENEDICTINE CARE CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331733310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN377175000Medicaid