Provider Demographics
NPI:1598416430
Name:GOPHER (MAPLE GROVE) TRS LLC
Entity Type:Organization
Organization Name:GOPHER (MAPLE GROVE) TRS LLC
Other - Org Name:HAVENWOOD OF MAPLE GLEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-754-8623
Mailing Address - Street 1:18695 73RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-6604
Mailing Address - Country:US
Mailing Address - Phone:763-363-8640
Mailing Address - Fax:
Practice Address - Street 1:18695 73RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-6604
Practice Address - Country:US
Practice Address - Phone:763-363-8640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility