Healthcare Provider Details

I. General information

NPI: 1588606461
Provider Name (Legal Business Name): LIFESPACE COMMUNITIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 HIGHWOOD DR
BLOOMINGTON MN
55438-1020
US

IV. Provider business mailing address

8100 HIGHWOOD DR
BLOOMINGTON MN
55438-1020
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-7500
  • Fax: 952-830-9893
Mailing address:
  • Phone: 952-831-7500
  • Fax: 952-830-9893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number332203
License Number StateMN

VIII. Authorized Official

Name: MR. SCOTT MICHAEL HARRISON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 515-288-5805