Healthcare Provider Details

I. General information

NPI: 1356231765
Provider Name (Legal Business Name): GRACE HAVEN SOBER LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 REANEY AVE E
SAINT PAUL MN
55119-3917
US

IV. Provider business mailing address

1772 PONDEROSA LN
NEW RICHMOND WI
54017-6626
US

V. Phone/Fax

Practice location:
  • Phone: 763-415-6301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: MS. PEG KINDA
Title or Position: CONTRACTOR
Credential:
Phone: 612-306-8499