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General NPI Number Information
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NPI Number | 1629242102
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Entity Type | Organization
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Legal Business Name | ASSISTED LIVING STORE, INCORPORATED
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Dates
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Enumeration Date | 04/16/2008
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Last Update Date | 04/16/2008
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Provider Practice Location Address
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Address Line | 7687 HYDE AVE S
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City | COTTAGE GROVE
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State | MN
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Zip | 55016-1978
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Country | US
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Telephone | 651-769-1574
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Fax | 651-768-7575
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Provider Business Mailing Address
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Address Line | 7687 HYDE AVE S
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City | COTTAGE GROVE
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State | MN
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Zip | 55016-1978
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Country | US
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Telephone | 651-769-1574
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Fax | 651-768-7575
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. KIMBERLY ANN CARLSON
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Credential |
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Telephone | 651-769-1574
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 4604156
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License Number State | MN
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