Provider Demographics
NPI:1508221136
Name:AUTUMN GLEN SENIOR LIVING LLC
Entity Type:Organization
Organization Name:AUTUMN GLEN SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-241-4428
Mailing Address - Street 1:3715 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2777
Mailing Address - Country:US
Mailing Address - Phone:763-772-4492
Mailing Address - Fax:763-746-4080
Practice Address - Street 1:3715 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2777
Practice Address - Country:US
Practice Address - Phone:763-772-4492
Practice Address - Fax:763-746-4080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-26
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN372324310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility