Healthcare Provider Details

I. General information

NPI: 1346328648
Provider Name (Legal Business Name): GARDEN TERRACE ASSISTED LIVING, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 MASON DR
WRENSHALL MN
55797-9030
US

IV. Provider business mailing address

426 MASON DR
WRENSHALL MN
55797-9030
US

V. Phone/Fax

Practice location:
  • Phone: 218-384-4623
  • Fax: 218-384-4508
Mailing address:
  • Phone: 218-384-4623
  • Fax: 218-384-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number332460
License Number StateMN

VIII. Authorized Official

Name: MRS. KELLY ANNE LAVEAU
Title or Position: PRESIDENT
Credential: R.N.
Phone: 218-384-4623