Provider Demographics
NPI:1811394968
Name:FCSL DETROIT LAKES, LLC
Entity Type:Organization
Organization Name:FCSL DETROIT LAKES, LLC
Other - Org Name:DIAMOND WILLOW ASSISTED LIVING OF DETROIT LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZELEZNIKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-625-8488
Mailing Address - Street 1:2701 W SUPERIOR ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-1856
Mailing Address - Country:US
Mailing Address - Phone:218-625-8488
Mailing Address - Fax:
Practice Address - Street 1:1558 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3745
Practice Address - Country:US
Practice Address - Phone:218-846-0825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN370704310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility