Provider Demographics
NPI:1790128049
Name:CHERRYWOOD ADVANCED LIVING, LLC
Entity Type:Organization
Organization Name:CHERRYWOOD ADVANCED LIVING, LLC
Other - Org Name:CHERRYWOOD ST CLOUD 1030
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HULSEBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-257-7445
Mailing Address - Street 1:1685 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2708
Mailing Address - Country:US
Mailing Address - Phone:320-257-7445
Mailing Address - Fax:320-257-7447
Practice Address - Street 1:1030 VOYAGEUR ST
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-257-7445
Practice Address - Fax:320-257-7447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN357491310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN360196OtherHOUSING WITH SERVICES LICENSE