Organization
NORTH STAR CLUB, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JASON FISCHER (MANAGER)
(952) 426-6219
Entity
Organization
Contact information
Practice address
8040 OLD CEDAR AVE S, BLOOMINGTON, MN 55425-1234
(952) 542-6219
Mailing address
8040 OLD CEDAR AVE S, BLOOMINGTON, MN 55425-1234
Taxonomy
Speciality
Code
Description
License number
State
311ZA0620X
Adult Care Home Facility
Primary
1066119
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1066119
LICENSE
MN
Enumeration date
08/26/2014
Last updated
08/26/2014
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