Provider Demographics
NPI:1104150044
Name:HERMANTOWN VALLEY ELDER CARE
Entity type:Organization
Organization Name:HERMANTOWN VALLEY ELDER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:MAJCHRZAK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:218-729-9831
Mailing Address - Street 1:5140 WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55810-2543
Mailing Address - Country:US
Mailing Address - Phone:218-729-9831
Mailing Address - Fax:
Practice Address - Street 1:5140 WAGNER RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55810-2543
Practice Address - Country:US
Practice Address - Phone:218-729-9831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1031815-4-AFC302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4980573OtherMEDICA