Healthcare Provider Details

I. General information

NPI: 1144964602
Provider Name (Legal Business Name): OWATONNA SENIOR LIVING COMMUNITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 W FRONTAGE RD
OWATONNA MN
55060-5692
US

IV. Provider business mailing address

654 NUTLEY PL
VALLEY STREAM NY
11581-3028
US

V. Phone/Fax

Practice location:
  • Phone: 507-451-0722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: CORY WAKE
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 303-883-9523