Provider Demographics
NPI:1477011807
Name:VALLEYVIEW OF JORDAN, LLC
Entity Type:Organization
Organization Name:VALLEYVIEW OF JORDAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-492-6160
Mailing Address - Street 1:4061 W 173RD ST
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-8318
Mailing Address - Country:US
Mailing Address - Phone:952-492-6160
Mailing Address - Fax:
Practice Address - Street 1:4061 W 173RD ST
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-8318
Practice Address - Country:US
Practice Address - Phone:952-492-6160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20964Medicaid