Provider Demographics
NPI:1295328300
Name:AVALON ADULT FOSTER CARE LLC
Entity type:Organization
Organization Name:AVALON ADULT FOSTER CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-289-2141
Mailing Address - Street 1:5001 NORTHWEST DR UNIT 1773
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55111-3033
Mailing Address - Country:US
Mailing Address - Phone:321-289-2141
Mailing Address - Fax:
Practice Address - Street 1:381 HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1912
Practice Address - Country:US
Practice Address - Phone:321-289-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency