Healthcare Provider Details

I. General information

NPI: 1972049708
Provider Name (Legal Business Name): GARDEN TERRACE ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 MASON DR
WRENSHALL MN
55797-9030
US

IV. Provider business mailing address

5401 SAMUELSON RD
DULUTH MN
55811-9710
US

V. Phone/Fax

Practice location:
  • Phone: 218-348-7588
  • Fax:
Mailing address:
  • Phone: 218-348-7588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL STANLEY PODGORNIK
Title or Position: PRESIDENT
Credential:
Phone: 218-348-7588