Healthcare Provider Details

I. General information

NPI: 1144319526
Provider Name (Legal Business Name): BONNIE'S SENIOR HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 RIDGEVIEW TER NE 1201 RIDGEVIEW TERRACE NE
ALEXANDRIA MN
56308-8684
US

IV. Provider business mailing address

1201 RIDGEVIEW TER NE 1201 RIDGEVIEW TERRACE NE
ALEXANDRIA MN
56308-8684
US

V. Phone/Fax

Practice location:
  • Phone: 320-759-6599
  • Fax: 320-759-6599
Mailing address:
  • Phone: 320-759-6599
  • Fax: 320-759-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number10183963AFC
License Number StateMN

VIII. Authorized Official

Name: BONITA MARIE NIENABER
Title or Position: OWNER
Credential:
Phone: 320-759-6599