Organization
MARTIN LUTHER MANOR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DENNIS R JOHNSON (CFO)
(651) 766-4300
Entity
Organization
Contact information
Practice address
1401 E 100TH ST, BLOOMINGTON, MN 55425-2615
(952) 888-7751
(952) 888-5465
Mailing address
3530 LEXINGTON AVE N, SAINT PAUL, MN 55126-8164
(651) 766-4300
(651) 766-4310
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
331915
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7122647
MEDICA
—
01
—
8606MA
BLUE CROSS BLUE SHIELD
MN
05
—
913423300
—
MN
01
—
NH0033
UCARE
MN
Enumeration date
07/21/2006
Last updated
08/22/2020
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