Provider Demographics
NPI:1760667489
Name:OAK TERRACE SENIOR HOUSING OF GAYLORD,LLC
Entity type:Organization
Organization Name:OAK TERRACE SENIOR HOUSING OF GAYLORD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MONTAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-381-1312
Mailing Address - Street 1:1570 TOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-2520
Mailing Address - Country:US
Mailing Address - Phone:507-387-2037
Mailing Address - Fax:507-387-6011
Practice Address - Street 1:716 SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MN
Practice Address - Zip Code:55334-2386
Practice Address - Country:US
Practice Address - Phone:507-237-2911
Practice Address - Fax:507-237-5744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN338323311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)