Provider Demographics
NPI:1750038295
Name:PHS-NORFOLK AVE LLC
Entity Type:Organization
Organization Name:PHS-NORFOLK AVE LLC
Other - Org Name:HIGHLAND PATH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-631-6450
Mailing Address - Street 1:2845 HAMLINE AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-7127
Mailing Address - Country:US
Mailing Address - Phone:651-631-6450
Mailing Address - Fax:651-631-6122
Practice Address - Street 1:1925 NORFOLK AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2575
Practice Address - Country:US
Practice Address - Phone:651-631-6100
Practice Address - Fax:651-631-6122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility