Provider Demographics
NPI:1205935152
Name:COVENANT LIVING OF GOLDEN VALLEY
Entity type:Organization
Organization Name:COVENANT LIVING OF GOLDEN VALLEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE VICE PRESIDENT OF HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLAREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-4430
Mailing Address - Street 1:5825 SAINT CROIX AVE N
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4419
Mailing Address - Country:US
Mailing Address - Phone:763-546-6125
Mailing Address - Fax:763-546-8529
Practice Address - Street 1:5825 SAINT CROIX AVE N
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4483
Practice Address - Country:US
Practice Address - Phone:763-546-6125
Practice Address - Fax:763-546-8529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245322Medicare Oscar/Certification