Healthcare Provider Details

I. General information

NPI: 1699008805
Provider Name (Legal Business Name): SHARON SHOFNER ADULT FOSTER CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 09/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8783 2ND ST SOUTH
BROOKSTON MN
55711
US

IV. Provider business mailing address

8783 2ND ST SOUTH
BROOKSTON MN
55711
US

V. Phone/Fax

Practice location:
  • Phone: 218-453-1083
  • Fax:
Mailing address:
  • Phone: 218-453-1083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number201343-3-AFC
License Number StateMN

VIII. Authorized Official

Name: MRS. SHARON CHLORINCE SHOFNER
Title or Position: CARE PROVIDER
Credential:
Phone: 218-453-1083