Provider Demographics
NPI:1902282866
Name:FARIBAULT OPS LLC
Entity Type:Organization
Organization Name:FARIBAULT OPS LLC
Other - Org Name:KEYSTONE FARIBUALT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVACZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-241-8204
Mailing Address - Street 1:7625 GOLDEN TRIANGLE DR
Mailing Address - Street 2:SUITE T
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3710
Mailing Address - Country:US
Mailing Address - Phone:952-241-8202
Mailing Address - Fax:
Practice Address - Street 1:828 1ST ST NE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5438
Practice Address - Country:US
Practice Address - Phone:507-332-2555
Practice Address - Fax:507-332-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility