Provider Demographics
NPI:1245396084
Name:KEYSTONE COMMUNITIES OF PRIOR LAKE
Entity Type:Organization
Organization Name:KEYSTONE COMMUNITIES OF PRIOR LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-836-2793
Mailing Address - Street 1:4685 PARK NICOLLET AVE SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4685 PARK NICOLLET AVE SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-3926
Practice Address - Country:US
Practice Address - Phone:952-836-2793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN333604177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes177F00000XOther Service ProvidersLodgingGroup - Single Specialty