MEDICARE: GRAND AVENUE REST HOME 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	310500000X	Mental Illness Intermediate Care Facility		MN

General Provider Information

NPI Number	:	1932196235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND AVENUE REST HOME INC

Provider Business Mailing Address
First Line	:	3956 GRAND AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55409-1535
Country	:	US
Telephone Number	:	612-824-1434
Fax Number	:	612-824-2219

Provider Business Practice Location Address
First Line	:	3956 GRAND AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55409-1535
Country	:	US
Telephone Number	:	612-824-1434
Fax Number	:	612-824-2219

Authorized Official
Title or Position	:	ACTING ADMINISTRATOR
Name	:	MRS. NANCY LYNN SODERBECK
Credential	:
Telephone Number	:	612-824-1434

Provider Enumeration Date	:	10/01/2005
Last Update Date	:	08/22/2020

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