Healthcare Provider Details

I. General information

NPI: 1780103929
Provider Name (Legal Business Name): ENRICHED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 COUNTY ROAD E2 W
NEW BRIGHTON MN
55112-6859
US

IV. Provider business mailing address

301 COUNTY ROAD E2 W
NEW BRIGHTON MN
55112-6859
US

V. Phone/Fax

Practice location:
  • Phone: 651-505-6766
  • Fax: 651-846-5633
Mailing address:
  • Phone: 651-505-6761
  • Fax: 651-846-5633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1086810
License Number StateMN

VIII. Authorized Official

Name: MR. TRYAN JOHNSON
Title or Position: OWNER
Credential:
Phone: 612-930-2265