Provider Demographics
NPI:1992782221
Name:SHOLOM HOME EAST INC
Entity type:Organization
Organization Name:SHOLOM HOME EAST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WYCKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-939-1637
Mailing Address - Street 1:740 KAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-6014
Mailing Address - Country:US
Mailing Address - Phone:651-328-2000
Mailing Address - Fax:651-328-2070
Practice Address - Street 1:740 KAY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-6014
Practice Address - Country:US
Practice Address - Phone:651-328-2000
Practice Address - Fax:651-328-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328527314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
8649SHOtherBLUE CROSS
7100365OtherMEDICA
7122642OtherMEDICA
00263OtherHEALTH PARTNERS
MN529242500Medicaid
NH0089OtherUCARE