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General NPI Number Information
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NPI Number | 1780765487
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Entity Type | Organization
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Legal Business Name | BRASK HAVEN INC
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 05/06/2024
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Provider Practice Location Address
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Address Line | 31274 JULLIARD ST NE
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City | NORTH BRANCH
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State | MN
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Zip | 55056-6546
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Country | US
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Telephone | 651-674-7433
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Fax | 651-237-0563
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Provider Business Mailing Address
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Address Line | 31274 JULLIARD ST NE
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City | NORTH BRANCH
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State | MN
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Zip | 55056-6546
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Country | US
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Telephone | 651-674-7433
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Fax | 651-237-0563
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Authorized Official
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Title or Position | CO-OWNER
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Name | ETTAFA BOKA
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Credential |
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Telephone | 651-448-9940
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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 | 330813
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License Number State | MN
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