Basic Information
| Provider Information | |||||||||
| NPI: | 1073564308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GGNSC FRIDLEY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDEN LIVINGCENTER - LYNWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 E RIVER RD | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554326149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635713150 | ||||||||
| FaxNumber: | 7635712805 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 E RIVER RD | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554326149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635713150 | ||||||||
| FaxNumber: | 7635712805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 331969 | MN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7122519 | 01 | MN | MEDICA CHOICE | OTHER | 115229 | 01 | MN | HEALTH PARTNERS MN | OTHER | 9R02FR | 01 | MN | BLUE CROSS MINNESOTA | OTHER | NH0200 | 01 | MN | UCARE MN | OTHER | 245201 | 01 | MN | SECURITY HEALTH PLAN | OTHER | 7100292 | 01 | MN | MEDICA SELECTCARE | OTHER | 937441800 | 05 | MN | MEDICAID |