Provider Demographics
NPI:1811299423
Name:FARIBAULT CARE CENTER
Entity type:Organization
Organization Name:FARIBAULT CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-5105
Mailing Address - Street 1:1738 HULETT AVE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2918
Mailing Address - Country:US
Mailing Address - Phone:507-334-3918
Mailing Address - Fax:507-332-2748
Practice Address - Street 1:1738 HULETT AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2918
Practice Address - Country:US
Practice Address - Phone:502-419-2571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DNR THREE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-02
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1811299423Medicaid
245097Medicare Oscar/Certification