Healthcare Provider Details

I. General information

NPI: 1790060838
Provider Name (Legal Business Name): STONEHAVEN ASSISTED LIVING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8783 2ND STREET SOUTH
BROOKSTON MN
55711-0284
US

IV. Provider business mailing address

8783 2ND STREET SOUTH
BROOKSTON MN
55711-0284
US

V. Phone/Fax

Practice location:
  • Phone: 218-453-5062
  • Fax: 218-453-5064
Mailing address:
  • Phone: 218-453-5062
  • Fax: 218-453-5064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number35448
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number354457
License Number StateMN

VIII. Authorized Official

Name: MRS. JENNIFER RENEE JOHNSON
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 218-453-5062