Provider Demographics
NPI:1518084847
Name:KEYSTONE FIVE STAR LLC
Entity Type:Organization
Organization Name:KEYSTONE FIVE STAR LLC
Other - Org Name:KEYSTONE BLUFFS ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEVIK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:218-625-2316
Mailing Address - Street 1:2528 TRINITY RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3315
Mailing Address - Country:US
Mailing Address - Phone:218-727-2800
Mailing Address - Fax:
Practice Address - Street 1:2528 TRINITY RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-3315
Practice Address - Country:US
Practice Address - Phone:218-727-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN334218310400000X
MN336667310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411936451OtherMEDICA
MN41-1936451OtherFIRST PLAN OF MINNESOTA
MN660078000OtherSTATE OF MN PROVIDER #