Provider Demographics
NPI:1508324443
Name:THE HOMESTEAD AT COON RAPIDS, INC.
Entity Type:Organization
Organization Name:THE HOMESTEAD AT COON RAPIDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-983-4249
Mailing Address - Street 1:1770 113TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3019
Mailing Address - Country:US
Mailing Address - Phone:763-754-2800
Mailing Address - Fax:763-754-4800
Practice Address - Street 1:1770 113TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3019
Practice Address - Country:US
Practice Address - Phone:763-754-2800
Practice Address - Fax:763-754-4800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-11
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPENDINGMedicaid