1528174349 NPI number — BEACON SPECIALIZED LIVING MINNESOTA, INC.

Table of content: (NPI 1528174349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528174349 NPI number — BEACON SPECIALIZED LIVING MINNESOTA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON SPECIALIZED LIVING MINNESOTA, 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:
Provider Other Organization Name Type Code:
6
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:
1528174349
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1355 MENDOTA HEIGHTS ROAD
Provider Second Line Business Mailing Address:
SUITE 260
Provider Business Mailing Address City Name:
MENDOTA HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-451-2889
Provider Business Mailing Address Fax Number:
651-451-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1355 MENDOTA HEIGHTS ROAD
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
MENDOTA HEIGHTS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-451-2889
Provider Business Practice Location Address Fax Number:
651-451-5955
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
651-451-2889

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP2482 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3104A0630X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 706520500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 211817300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108343100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24G272 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196680400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 246318 . This is a "MEDICAID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 339343700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 392150600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 579133200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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