Provider Demographics
NPI:1306259056
Name:SOUTHERN MINNESOTA HOME CARE
Entity type:Organization
Organization Name:SOUTHERN MINNESOTA HOME CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SONTAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-257-2252
Mailing Address - Street 1:213 PARKWAY AVE
Mailing Address - Street 2:PO BOX 375
Mailing Address - City:EAGLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56024-7709
Mailing Address - Country:US
Mailing Address - Phone:507-257-2252
Mailing Address - Fax:
Practice Address - Street 1:213 PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:56024-7709
Practice Address - Country:US
Practice Address - Phone:507-257-2252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN MINNESOTA HOME CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-10
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN346457305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1295060077Medicaid
MNA864907100Medicaid
MNA632620100Medicaid