Healthcare Provider Details

I. General information

NPI: 1528174349
Provider Name (Legal Business Name): BEACON SPECIALIZED LIVING MINNESOTA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 MENDOTA HEIGHTS ROAD SUITE 260
MENDOTA HEIGHTS MN
55120
US

IV. Provider business mailing address

1355 MENDOTA HEIGHTS RD STE 260
MENDOTA HEIGHTS MN
55120-1168
US

V. Phone/Fax

Practice location:
  • Phone: 651-451-2889
  • Fax: 651-451-5955
Mailing address:
  • Phone: 651-451-2889
  • Fax: 651-451-5955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MARLENE HERNANDEZ
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 608-982-9762