Provider Demographics
NPI:1437507332
Name:AUTUMN WOODS III, LLC
Entity Type:Organization
Organization Name:AUTUMN WOODS III, LLC
Other - Org Name:THE LEGACY OF ST. ANTHONY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-697-4681
Mailing Address - Street 1:4601 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 650
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4960
Mailing Address - Country:US
Mailing Address - Phone:952-697-4681
Mailing Address - Fax:952-925-5640
Practice Address - Street 1:2540 KENZIE TER
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-4165
Practice Address - Country:US
Practice Address - Phone:952-697-4681
Practice Address - Fax:952-925-5640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN374017310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility