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General NPI Number Information
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NPI Number | 1902282866
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Entity Type | Organization
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Legal Business Name | FARIBAULT OPS LLC
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Dates
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Enumeration Date | 08/03/2015
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Last Update Date | 08/03/2015
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Provider Practice Location Address
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Address Line | 828 1ST ST NE
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City | FARIBAULT
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State | MN
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Zip | 55021-5438
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Country | US
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Telephone | 507-332-2555
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Fax | 507-332-9010
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Provider Business Mailing Address
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Address Line | 7625 GOLDEN TRIANGLE DR SUITE T
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3710
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Country | US
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Telephone | 952-241-8202
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RYAN NOVACZYK
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Credential |
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Telephone | 952-241-8204
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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 |
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License Number State |
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