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Organization
PROVENANCE HOMES 1, LLC
Active
Organization
PROVENANCE HOMES 1, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK CALEB GLOBUS (CHIEF MANAGER)
(612) 940-2104
Entity
Organization
Contact information
Practice address
3641 28TH AVE S UNIT 1, MINNEAPOLIS, MN 55406-2515
(612) 940-2104
Mailing address
1650 W END BLVD STE 100, ST LOUIS PARK, MN 55416-5369
(612) 940-2104
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
—
—
Other
Enumeration date
03/25/2024
Last updated
03/25/2024
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