MEDICARE: SHERBURN ECONOMIC DEVELOPMENT AUTHORITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	329269	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	329269	OTHER	MN	HWS

General Provider Information

NPI Number	:	1285690347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHERBURN ECONOMIC DEVELOPMENT AUTHORITY

Provider Business Mailing Address
First Line	:	410 FOX LAKE AVE
Second Line	:
City	:	SHERBURN
State	:	MN
Zip	:	56171-9605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 FOX LAKE AVE
Second Line	:
City	:	SHERBURN
State	:	MN
Zip	:	56171-9605
Country	:	US
Telephone Number	:	952-888-2923
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HOWIE GROFF
Credential	:
Telephone Number	:	952-888-2923

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	06/18/2008

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