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General NPI Number Information
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NPI Number | 1265754980
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Entity Type | Organization
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Legal Business Name | EBENEZER RIDGES ASSISTED LIVING
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Dates
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Enumeration Date | 02/22/2010
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Last Update Date | 02/22/2010
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Provider Practice Location Address
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Address Line | 13810 COMMUNITY DR
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City | BURNSVILLE
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State | MN
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Zip | 55337-4593
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Country | US
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Telephone | 952-898-4005
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Fax | 952-435-6686
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Provider Business Mailing Address
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Address Line | 13810 COMMUNITY DR
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City | BURNSVILLE
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State | MN
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Zip | 55337-4593
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Country | US
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Telephone | 952-898-4005
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Fax | 952-435-6686
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Authorized Official
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Title or Position | CFO
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Name | STEPHAN GRYGAR
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Credential |
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Telephone | 612-874-3477
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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 | 341422
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License Number State | MN
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