Healthcare Provider Details

I. General information

NPI: 1144787441
Provider Name (Legal Business Name): ELEVATED ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2019
Last Update Date: 02/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14410 21ST ST N
WEST LAKELAND MN
55082-2514
US

IV. Provider business mailing address

7672 W 84TH ST
BLOOMINGTON MN
55438-1304
US

V. Phone/Fax

Practice location:
  • Phone: 612-770-3878
  • Fax:
Mailing address:
  • Phone: 612-770-3878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DAVID A ITMAN
Title or Position: OWNER/CEO
Credential:
Phone: 612-770-3878