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
StateLicense IDTaxonomies
MN24404310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility