Healthcare Provider Details

I. General information

NPI: 1407336118
Provider Name (Legal Business Name): ROYAL STAR RESIDENCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 SHINGLE CREEK PKWY N SUITE 500Q
BROOKLYN CENTER MN
55430-2386
US

IV. Provider business mailing address

5701 SHINGLE CREEK PKWY N SUITE 500Q
BROOKLYN CENTER MN
55430-2386
US

V. Phone/Fax

Practice location:
  • Phone: 763-442-5136
  • Fax:
Mailing address:
  • Phone: 763-442-5136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTIAN KANMUE KOLLEH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 763-442-5136