Healthcare Provider Details

I. General information

NPI: 1477442143
Provider Name (Legal Business Name): BLANK SLATE HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 PACIFIC ST
SAINT PAUL MN
55106-6421
US

IV. Provider business mailing address

PO BOX 242
CENTER CITY MN
55012-0242
US

V. Phone/Fax

Practice location:
  • Phone: 612-770-5748
  • Fax:
Mailing address:
  • Phone: 612-770-5748
  • 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: MRS. ELIZABETH LEEANN GLENNA
Title or Position: VICE PRESIDENT
Credential: PT
Phone: 612-770-5748