Provider Demographics
NPI:1942436985
Name:CORNERSTONE RESIDENCE OF BAGLEY, INC
Entity Type:Organization
Organization Name:CORNERSTONE RESIDENCE OF BAGLEY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-435-6205
Mailing Address - Street 1:30 SUNSET AVE SW
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621
Mailing Address - Country:US
Mailing Address - Phone:218-694-2701
Mailing Address - Fax:218-694-2718
Practice Address - Street 1:30 SUNSET AVE SW
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621
Practice Address - Country:US
Practice Address - Phone:218-694-2701
Practice Address - Fax:218-694-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility