Provider Demographics
NPI:1467638379
Name:SUPPORTIVE LIVING SERVICES, INC.
Entity Type:Organization
Organization Name:SUPPORTIVE LIVING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOFTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-277-1020
Mailing Address - Street 1:5615 BROOKLYN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3086
Mailing Address - Country:US
Mailing Address - Phone:763-537-6612
Mailing Address - Fax:763-537-7162
Practice Address - Street 1:5615 BROOKLYN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3086
Practice Address - Country:US
Practice Address - Phone:763-537-6612
Practice Address - Fax:763-537-7162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN004974300Medicare UPIN