Provider Demographics
NPI:1588176432
Name:BROOKSTONE MANOR, INC.
Entity Type:Organization
Organization Name:BROOKSTONE MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ROCHELEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-302-0192
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:ROYALTON
Mailing Address - State:MN
Mailing Address - Zip Code:56373-0391
Mailing Address - Country:US
Mailing Address - Phone:320-302-0192
Mailing Address - Fax:320-302-0194
Practice Address - Street 1:722 N POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2669
Practice Address - Country:US
Practice Address - Phone:218-326-3469
Practice Address - Fax:218-326-5339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility