Provider Demographics
NPI:1003368309
Name:AMAZING LOVE ELDERLY CARE CENTER LLC
Entity Type:Organization
Organization Name:AMAZING LOVE ELDERLY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:POLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-296-1872
Mailing Address - Street 1:31 10TH ST NW
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-5118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7807 EMERALD RD
Practice Address - Street 2:
Practice Address - City:RANDALL
Practice Address - State:MN
Practice Address - Zip Code:56475-2428
Practice Address - Country:US
Practice Address - Phone:320-749-2485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1083851311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home