Provider Demographics
NPI:1609007061
Name:GJ DESTINY ADULT FOSTER HOME, LLC
Entity Type:Organization
Organization Name:GJ DESTINY ADULT FOSTER HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PUFAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-692-4790
Mailing Address - Street 1:14295 82ND ST NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-6812
Mailing Address - Country:US
Mailing Address - Phone:320-692-4790
Mailing Address - Fax:
Practice Address - Street 1:14295 82ND ST NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-6812
Practice Address - Country:US
Practice Address - Phone:320-692-4790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1055022 1 AFC385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care