MEDICARE: BEACON SPECIALIZED LIVING MINNESOTA, INC.

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	103T00000X	Psychologist	LP2482	MN
2	310400000X	Assisted Living Facility
3	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
4	311Z00000X	Custodial Care Facility
5	261QA0600X	Adult Day Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528174349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACON SPECIALIZED LIVING MINNESOTA, INC.

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

Provider Business Practice Location Address
First Line	:	1355 MENDOTA HEIGHTS ROAD
Second Line	:	SUITE 260
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120
Country	:	US
Telephone Number	:	651-451-2889
Fax Number	:	651-451-5955

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/26/2021

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