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General NPI Number Information
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NPI Number | 1992004071
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Entity Type | Organization
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Legal Business Name | BRECK HOME RESIDENTIAL CARE CENTER, LLC
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Dates
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Enumeration Date | 03/15/2011
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Last Update Date | 03/15/2011
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Provider Practice Location Address
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Address Line | 312 W 95TH ST
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City | BLOOMINGTON
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State | MN
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Zip | 55420-4311
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Country | US
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Telephone | 612-702-8801
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Fax |
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Provider Business Mailing Address
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Address Line | 312 W 95TH ST
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City | BLOOMINGTON
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State | MN
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Zip | 55420-4311
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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 | OWNER/OPERATOR
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Name | JENNIFER MORGAN
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Credential | MS, RN
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Telephone | 612-702-8801
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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 | 352080
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License Number State | MN
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