Healthcare Provider Details

I. General information

NPI: 1780765487
Provider Name (Legal Business Name): BRASK HAVEN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31274 JULLIARD ST NE
NORTH BRANCH MN
55056-6546
US

IV. Provider business mailing address

31274 JULLIARD ST NE
NORTH BRANCH MN
55056-6546
US

V. Phone/Fax

Practice location:
  • Phone: 651-674-7433
  • Fax: 651-237-0563
Mailing address:
  • Phone: 651-674-7433
  • Fax: 651-237-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number330813
License Number StateMN

VIII. Authorized Official

Name: ETTAFA BOKA
Title or Position: CO-OWNER
Credential:
Phone: 651-448-9940