Healthcare Provider Details

I. General information

NPI: 1114232949
Provider Name (Legal Business Name): SEPTEMBER COTTAGE ELDERCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14145 205TH ST N
SCANDIA MN
55073-9583
US

IV. Provider business mailing address

14145 205TH ST N
SCANDIA MN
55073-9583
US

V. Phone/Fax

Practice location:
  • Phone: 651-433-4638
  • Fax:
Mailing address:
  • Phone: 651-433-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number1057930-2-AFC
License Number StateMN

VIII. Authorized Official

Name: MS. ALANA NICOLE SUNDBERG
Title or Position: OWNER/PROVIDER
Credential:
Phone: 651-433-4638