Healthcare Provider Details

I. General information

NPI: 1326226853
Provider Name (Legal Business Name): PARK LANE ESTATES ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FILLMORE PL SE
PRESTON MN
55965-1140
US

IV. Provider business mailing address

111 FILLMORE PL SE
PRESTON MN
55965-1140
US

V. Phone/Fax

Practice location:
  • Phone: 507-765-9986
  • Fax: 507-765-9987
Mailing address:
  • Phone: 507-765-9986
  • Fax: 507-765-9987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number5399731
License Number StateMN

VIII. Authorized Official

Name: CHUCK LANE
Title or Position: OWNER
Credential:
Phone: 218-692-6640