Provider Demographics
NPI:1891179271
Name:BENEDICTINE LIVING COMMUNITY OF MORA
Entity Type:Organization
Organization Name:BENEDICTINE LIVING COMMUNITY OF MORA
Other - Org Name:EASTWOOD SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:L'HEUREUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-679-8312
Mailing Address - Street 1:170 VALHALLA CIR
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-4905
Mailing Address - Country:US
Mailing Address - Phone:320-679-4789
Mailing Address - Fax:
Practice Address - Street 1:170 VALHALLA CIR
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-4905
Practice Address - Country:US
Practice Address - Phone:320-679-4789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN371951310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility