Provider Demographics
NPI:1639347354
Name:FIVE STAR LIVING OF CLOQUET LLC
Entity Type:Organization
Organization Name:FIVE STAR LIVING OF CLOQUET LLC
Other - Org Name:DIAMOND WILLOW ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEVIK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:218-625-2316
Mailing Address - Street 1:11 E SUPERIOR ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2007
Mailing Address - Country:US
Mailing Address - Phone:218-625-2316
Mailing Address - Fax:218-625-2338
Practice Address - Street 1:130 NORTH RD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1171
Practice Address - Country:US
Practice Address - Phone:218-625-2316
Practice Address - Fax:218-625-2338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE STAR ASSISTED LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN336184310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility