Healthcare Provider Details

I. General information

NPI: 1295891042
Provider Name (Legal Business Name): KEYSTONE COMMUNITIES OF EAGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 ALDER LN
EAGAN MN
55122-3831
US

IV. Provider business mailing address

3810 ALDER LN
EAGAN MN
55122-3831
US

V. Phone/Fax

Practice location:
  • Phone: 952-836-2793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number334028
License Number StateMN

VIII. Authorized Official

Name: DONNA TEFF
Title or Position: ACCOUNTS SUPERVISOR
Credential:
Phone: 952-836-2793