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General NPI Number Information
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NPI Number | 1104603299
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Entity Type | Organization
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Legal Business Name | WALNUT GROVE HOME
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Dates
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Enumeration Date | 09/12/2023
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Last Update Date | 09/12/2023
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Provider Practice Location Address
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Address Line | 13708 PORTLAND AVE
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City | BURNSVILLE
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State | MN
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Zip | 55337-4128
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Country | US
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Telephone | 320-223-9249
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Fax |
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Provider Business Mailing Address
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Address Line | 6601 ZIRCON LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55311-1371
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Country | US
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Telephone | 320-223-9249
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JINYI SLAGLE WU
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Credential |
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Telephone | 320-223-9249
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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