Provider Demographics
NPI: | 1013089911 |
---|---|
Name: | GOLDEN VALLEY RESIDENCE |
Entity Type: | Organization |
Organization Name: | GOLDEN VALLEY RESIDENCE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | MARCIA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DOONER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 763-550-1774 |
Mailing Address - Street 1: | 4205 LANCASTER LN N |
Mailing Address - Street 2: | SUITE 109 |
Mailing Address - City: | PLYMOUTH |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55441-1700 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 763-550-1774 |
Mailing Address - Fax: | 763-559-9155 |
Practice Address - Street 1: | 1940 MAJOR DR N |
Practice Address - Street 2: | |
Practice Address - City: | GOLDEN VALLEY |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55422-4155 |
Practice Address - Country: | US |
Practice Address - Phone: | 763-521-4839 |
Practice Address - Fax: | 763-521-4148 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-11-15 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 24404 | 310400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility |