Organization
GRACEFUL LODGE, LLC
Active
Other names
GRACEFUL LODGE HOME CARE
Organization subpart
No
Provider details
NPI number
Authorized official
DANIEL S. BREWER (ADMINISTRATOR)
(763) 496-9056
Entity
Organization
Contact information
Practice address
6430 JUNE AVE N, BROOKLYN CENTER, MN 55429-2127
(763) 496-9056
Mailing address
3300 COUNTY ROAD 10 STE 320F, BROOKLYN CENTER, MN 55429-3072
(763) 496-9056
(763) 374-3882
Taxonomy
Speciality
Code
Description
License number
State
251E00000X
Home Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
394111
COMPREHENSIVE LICENSED HOME CARE SERVICE
MN
Enumeration date
12/13/2019
Last updated
12/15/2019
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