Provider Demographics
NPI:1588606461
Name:LIFESPACE COMMUNITIES INC
Entity Type:Organization
Organization Name:LIFESPACE COMMUNITIES INC
Other - Org Name:FRIENDSHIP VILLAGE OF BLOOMINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-288-5805
Mailing Address - Street 1:8100 HIGHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1020
Mailing Address - Country:US
Mailing Address - Phone:952-831-7500
Mailing Address - Fax:952-830-9893
Practice Address - Street 1:8100 HIGHWOOD DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-1020
Practice Address - Country:US
Practice Address - Phone:952-831-7500
Practice Address - Fax:952-830-9893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPACE COMMUNITIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-12
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332203314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNH0298OtherUCARE
MN71-22549OtherMEDICA
MN8773FROtherBLUE CROSS BLUE SHIELD
MN245229Medicare Oscar/Certification