Healthcare Provider Details

I. General information

NPI: 1396839148
Provider Name (Legal Business Name): ROBERT LENNARTSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8251 INGLESIDE AVE SOUTH
COTTAGE GROVE MN
55016
US

IV. Provider business mailing address

8251 INGLESIDE AVE SOUTH
COTTAGE GROVE MN
55016
US

V. Phone/Fax

Practice location:
  • Phone: 651-458-0813
  • Fax: 651-769-2620
Mailing address:
  • Phone: 651-458-0813
  • Fax: 651-769-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number235363-4-AFC
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number235363-2-AFC
License Number StateMN

VIII. Authorized Official

Name: MR. ROBERT BLAKE LENNARTSON
Title or Position: OWNER
Credential:
Phone: 651-458-0813