MEDICARE: BONNIE'S SENIOR HAVEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	10183963AFC	MN

General Provider Information

NPI Number	:	1144319526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONNIE'S SENIOR HAVEN

Provider Business Mailing Address
First Line	:	1201 RIDGEVIEW TER NE
Second Line	:	1201 RIDGEVIEW TERRACE NE
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-8684
Country	:	US
Telephone Number	:	320-759-6599
Fax Number	:	320-759-6599

Provider Business Practice Location Address
First Line	:	1201 RIDGEVIEW TER NE
Second Line	:	1201 RIDGEVIEW TERRACE NE
City	:	ALEXANDRIA
State	:	MN
Zip	:	56308-8684
Country	:	US
Telephone Number	:	320-759-6599
Fax Number	:	320-759-6599

Authorized Official
Title or Position	:	OWNER
Name	:	BONITA MARIE NIENABER
Credential	:
Telephone Number	:	320-759-6599

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	08/07/2008

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