Provider Demographics
NPI:1215932728
Name:VILLA ST. VINCENT
Entity type:Organization
Organization Name:VILLA ST. VINCENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HULST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-281-9700
Mailing Address - Street 1:516 WALSH ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716
Mailing Address - Country:US
Mailing Address - Phone:218-281-3424
Mailing Address - Fax:218-281-4755
Practice Address - Street 1:516 WALSH ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716
Practice Address - Country:US
Practice Address - Phone:218-281-3424
Practice Address - Fax:218-281-4755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN325662310400000X
MN353890310400000X
MN328575314000000X
MN352789314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8756VIOtherBLUE CROSS INSURANCE
MN177240600Medicaid
MN177240600Medicaid
MN=========OtherFEDERAL I D
1215932728Medicare UPIN