Provider Demographics
NPI:1972049708
Name:GARDEN TERRACE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:GARDEN TERRACE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:PODGORNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-348-7588
Mailing Address - Street 1:5401 SAMUELSON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-9710
Mailing Address - Country:US
Mailing Address - Phone:218-348-7588
Mailing Address - Fax:
Practice Address - Street 1:426 MASON DR
Practice Address - Street 2:
Practice Address - City:WRENSHALL
Practice Address - State:MN
Practice Address - Zip Code:55797-9030
Practice Address - Country:US
Practice Address - Phone:218-348-7588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility