Provider Demographics
NPI:1528174349
Name:BEACON SPECIALIZED LIVING MINNESOTA, INC.
Entity type:Organization
Organization Name:BEACON SPECIALIZED LIVING MINNESOTA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-451-2889
Mailing Address - Street 1:1355 MENDOTA HEIGHTS ROAD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120
Mailing Address - Country:US
Mailing Address - Phone:651-451-2889
Mailing Address - Fax:651-451-5955
Practice Address - Street 1:1355 MENDOTA HEIGHTS ROAD
Practice Address - Street 2:SUITE 260
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120
Practice Address - Country:US
Practice Address - Phone:651-451-2889
Practice Address - Fax:651-451-5955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2482103T00000X
310400000X, 3104A0630X, 311Z00000X, 261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN706520500Medicaid
MN211817300Medicaid
MN108343100Medicaid
MN24G272Medicaid
MN196680400Medicaid
MN246318OtherMEDICAID
MN339343700Medicaid
MN392150600Medicaid
MN579133200Medicaid