Provider Demographics
NPI:1942071972
Name:PARK LANE ESTATES OF PRESTON, LLC
Entity Type:Organization
Organization Name:PARK LANE ESTATES OF PRESTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABDULLAHI
Authorized Official - Middle Name:
Authorized Official - Last Name:OMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-404-6892
Mailing Address - Street 1:2277 HIGHWAY 36 W STE 300
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3830
Mailing Address - Country:US
Mailing Address - Phone:612-404-6892
Mailing Address - Fax:
Practice Address - Street 1:111 FILLMORE PLACE SE
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:MN
Practice Address - Zip Code:55965
Practice Address - Country:US
Practice Address - Phone:507-765-9986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility