Provider Demographics
NPI:1821187220
Name:GARDEN LANE ASSISTED LIVING
Entity Type:Organization
Organization Name:GARDEN LANE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:KINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-751-0583
Mailing Address - Street 1:9748 PONY LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5986
Mailing Address - Country:US
Mailing Address - Phone:218-751-9442
Mailing Address - Fax:
Practice Address - Street 1:10240 N GARDEN LN NE
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-8555
Practice Address - Country:US
Practice Address - Phone:218-751-0583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNFBL-0018779-22147310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility