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General NPI Number Information
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NPI Number | 1942713102
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Entity Type | Organization
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Legal Business Name | PARK PLACE SENIOR LIVING, LLC
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Dates
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Enumeration Date | 11/09/2017
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Last Update Date | 11/09/2017
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Provider Practice Location Address
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Address Line | 125 E PARK ST
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City | OWATONNA
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State | MN
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Zip | 55060-4067
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Country | US
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Telephone | 507-451-0808
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Fax |
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Provider Business Mailing Address
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Address Line | 1995 E RUM RIVER DR S
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City | CAMBRIDGE
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State | MN
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Zip | 55008-2656
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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 | CEO/ADMINISTRATOR
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Name | DAVE VANDERGON
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Credential |
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Telephone | 612-961-9672
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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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