Healthcare Provider Details

I. General information

NPI: 1699732420
Provider Name (Legal Business Name): COLONY AT EDEN PRAIRIE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 PRAIRIE CENTER DR
EDEN PRAIRIE MN
55344-5378
US

IV. Provider business mailing address

429 PRAIRIE CENTER DR
EDEN PRAIRIE MN
55344-5378
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-2923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number328765
License Number StateMN

VIII. Authorized Official

Name: KYLE DIDIER
Title or Position: PRESIDENT
Credential:
Phone: 952-358-5100