Healthcare Provider Details

I. General information

NPI: 1770624256
Provider Name (Legal Business Name): FOUNDATIONS GROUP OF MN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31100 FOREST BLVD BLDG B
STACY MN
55079-9247
US

IV. Provider business mailing address

PO BOX 247
STACY MN
55079-0247
US

V. Phone/Fax

Practice location:
  • Phone: 651-408-1433
  • Fax: 651-408-1434
Mailing address:
  • Phone: 651-408-1433
  • Fax: 651-408-1434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1041613-1-WS
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMN

VIII. Authorized Official

Name: MRS. KIMBERLY ERIN SMITH
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 651-408-1433