Provider Demographics
NPI:1740637859
Name:GREEN GABLES ASSISTED LIVING LLC
Entity type:Organization
Organization Name:GREEN GABLES ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:POLK-PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:763-229-2287
Mailing Address - Street 1:614 EMMA DR SE
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:MN
Mailing Address - Zip Code:56320-1454
Mailing Address - Country:US
Mailing Address - Phone:320-348-9142
Mailing Address - Fax:320-686-0231
Practice Address - Street 1:614 EMMA DR SE
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:MN
Practice Address - Zip Code:56320-1454
Practice Address - Country:US
Practice Address - Phone:320-348-9142
Practice Address - Fax:320-686-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNHFID - 32338310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility