Provider Demographics
NPI:1285690347
Name:SHERBURN ECONOMIC DEVELOPMENT AUTHORITY
Entity Type:Organization
Organization Name:SHERBURN ECONOMIC DEVELOPMENT AUTHORITY
Other - Org Name:TEMPERANCE LAKE RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-888-2923
Mailing Address - Street 1:410 FOX LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHERBURN
Mailing Address - State:MN
Mailing Address - Zip Code:56171-9605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 FOX LAKE AVE
Practice Address - Street 2:
Practice Address - City:SHERBURN
Practice Address - State:MN
Practice Address - Zip Code:56171-9605
Practice Address - Country:US
Practice Address - Phone:952-888-2923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN329269310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN250473100Medicaid
MN329269OtherHWS