Provider Demographics
NPI:1356191928
Name:PROVENANCE HOMES 1, LLC
Entity type:Organization
Organization Name:PROVENANCE HOMES 1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CALEB
Authorized Official - Last Name:GLOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-940-2104
Mailing Address - Street 1:1650 W END BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5369
Mailing Address - Country:US
Mailing Address - Phone:612-940-2104
Mailing Address - Fax:
Practice Address - Street 1:3641 28TH AVE S UNIT 1
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2515
Practice Address - Country:US
Practice Address - Phone:612-940-2104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility