Basic Information
| Provider Information | |||||||||
| NPI: | 1134426778 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOND DU LAC RESERVATION BUSINESS COMMITTEE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOND DU LAC ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 TRETTEL LANE | ||||||||
| Address2: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188783755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1571 AIRPORT ROAD | ||||||||
| Address2: | FOND DU LAC ASSISTED LIVING | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188783755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 03/22/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROVER | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2188791227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 348710 | MN | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | 25541M | MN | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 310400000X | 349645 | MN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.