=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144964602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OWATONNA SENIOR LIVING COMMUNITY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2022
-----------------------------------------------------
Last Update Date | 04/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1212 W FRONTAGE RD
-----------------------------------------------------
City | OWATONNA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55060-5692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-451-0722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 654 NUTLEY PL
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11581-3028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED REPRESENTATIVE
-----------------------------------------------------
Name | CORY WAKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-883-9523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------