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: 07/26/2021
Certification Date: 07/26/2021
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 ROAD SUITE 260
MENDOTA HEIGHTS MN
55120
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 TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP2482
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARBARA TURNER
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 651-451-2889