Healthcare Provider Details

I. General information

NPI: 1770628778
Provider Name (Legal Business Name): NORTHEAST RESIDENCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LITTLE CANADA RD E
LITTLE CANADA MN
55117-1629
US

IV. Provider business mailing address

410 LITTLE CANADA RD E
LITTLE CANADA MN
55117-1629
US

V. Phone/Fax

Practice location:
  • Phone: 651-765-0217
  • Fax: 651-765-0212
Mailing address:
  • Phone: 651-765-0217
  • Fax: 651-765-0212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number801750
License Number StateMN

VIII. Authorized Official

Name: MRS. CORRINE MAE SCHMIDT
Title or Position: ADMINISTRATOR
Credential:
Phone: 651-765-0217