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General NPI Number Information
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NPI Number | 1356231765
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Entity Type | Organization
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Legal Business Name | GRACE HAVEN SOBER LIVING LLC
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Dates
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Enumeration Date | 07/07/2025
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Last Update Date | 07/07/2025
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Provider Practice Location Address
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Address Line | 1940 REANEY AVE E
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City | SAINT PAUL
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State | MN
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Zip | 55119-3917
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Country | US
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Telephone | 763-415-6301
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Fax |
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Provider Business Mailing Address
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Address Line | 1772 PONDEROSA LN
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City | NEW RICHMOND
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State | WI
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Zip | 54017-6626
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CONTRACTOR
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Name | MS. PEG KINDA
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Credential |
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Telephone | 612-306-8499
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 177F00000X
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Taxonomy Name | Lodging Provider
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License Number |
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License Number State |
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