Provider Demographics
NPI:1629361092
Name:VALLEY SENIOR SERVICES ALLIANCE
Entity Type:Organization
Organization Name:VALLEY SENIOR SERVICES ALLIANCE
Other - Org Name:BOUTWELLS LANDING ADULT DAY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF CREATIVE INDE
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-631-6123
Mailing Address - Street 1:2845 HAMLINE AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-631-6187
Mailing Address - Fax:651-631-6122
Practice Address - Street 1:5610 NORWICH PARKWAY
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:851-275-5801
Practice Address - Fax:651-275-5802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALLEY SENIOR SERVICES ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1064266-1-ADC261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care