MEDICARE: WEST BLOOMINGTON RESIDENCE

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
2	310400000X	Assisted Living Facility	334473	MN

General Provider Information

NPI Number	:	1366566572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST BLOOMINGTON RESIDENCE

Provider Business Mailing Address
First Line	:	10441 JOHNSON AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55437-2819
Country	:	US
Telephone Number	:	763-550-1774
Fax Number	:

Provider Business Practice Location Address
First Line	:	10441 JOHNSON AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55437-2819
Country	:	US
Telephone Number	:	763-550-1774
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARCIA SUE DOONER
Credential	:
Telephone Number	:	763-550-1774

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	04/25/2008

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Directions to “WEST BLOOMINGTON RESIDENCE ” Practice Location

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