Healthcare Provider Details

I. General information

NPI: 1720293269
Provider Name (Legal Business Name): LIVING SERVICES FOUNDATION NEW LONDON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GLENOAKS DR
NEW LONDON MN
56273-9580
US

IV. Provider business mailing address

100 GLENOAKS DR
NEW LONDON MN
56273-9580
US

V. Phone/Fax

Practice location:
  • Phone: 320-354-2173
  • Fax: 320-354-2060
Mailing address:
  • Phone: 320-354-2173
  • Fax: 320-354-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number00314
License Number StateMN

VIII. Authorized Official

Name: MS. KRYSS GIMSE
Title or Position: FINANCIAL SERVICES DIRECTOR
Credential:
Phone: 320-354-6067