Provider Demographics
NPI:1629616289
Name:GRACEFUL LODGE, LLC
Entity Type:Organization
Organization Name:GRACEFUL LODGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-496-9056
Mailing Address - Street 1:3300 COUNTY ROAD 10 STE 320F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3072
Mailing Address - Country:US
Mailing Address - Phone:763-496-9056
Mailing Address - Fax:763-374-3882
Practice Address - Street 1:6430 JUNE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2127
Practice Address - Country:US
Practice Address - Phone:763-496-9056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN394111OtherCOMPREHENSIVE LICENSED HOME CARE SERVICE