Healthcare Provider Details

I. General information

NPI: 1689374803
Provider Name (Legal Business Name): SOLACE ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6718 QUAIL AVE N
BROOKLYN CENTER MN
55429-1656
US

IV. Provider business mailing address

6718 QUAIL AVE N
BROOKLYN CENTER MN
55429-1656
US

V. Phone/Fax

Practice location:
  • Phone: 612-814-8012
  • Fax:
Mailing address:
  • Phone: 612-814-8012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: UBAH A YUSUF
Title or Position: MANAGER
Credential:
Phone: 612-229-1637