Basic Information
| Provider Information | |||||||||
| NPI: | 1902343353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVALON HOSPICE MINNESOTA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4060 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281174060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046642876 | ||||||||
| FaxNumber: | 7046641306 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 PARK ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551032142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123610022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2017 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF LICENSURE | ||||||||
| AuthorizedOfficialTelephone: | 9138142013 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 1902343353 | 05 | MN | MEDICAID |