1326069642 NPI number — THE HOMESTEAD AT ANOKA, INC.

Table of content: (NPI 1326069642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326069642 NPI number — THE HOMESTEAD AT ANOKA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE HOMESTEAD AT ANOKA, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ANOKA REHABILITATION AND LIVING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326069642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7485 OFFICE RIDGE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55344-3690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-941-0305
Provider Business Mailing Address Fax Number:
952-941-0428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANOKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55303-1203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-528-6400
Provider Business Practice Location Address Fax Number:
763-528-6479
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAVIN
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
612-428-7840

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  330543 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7111783 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6C77AN . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 261960100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 92334 . This is a "HP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NH0132 . This is a "U-CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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