MEDICARE: SMC AHSTON INC

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

General Provider Information

NPI Number	:	1407531767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMC AHSTON INC

Provider Business Mailing Address
First Line	:	7100 NORTHLAND CIR N STE 207
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-1500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7435 78TH CT N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55445-2757
Country	:	US
Telephone Number	:	763-566-0831
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ROGER BONNY
Credential	:
Telephone Number	:	763-566-0831

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	06/15/2023

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