=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003368309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMAZING LOVE ELDERLY CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2016
-----------------------------------------------------
Last Update Date | 11/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7807 EMERALD RD
-----------------------------------------------------
City | RANDALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56475-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-749-2485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 10TH ST NW
-----------------------------------------------------
City | STAPLES
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56479-5118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | PENNY JEAN POLING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-296-1872
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 1083851
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------