Provenance Homes 1, LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

Legal business name

PROVENANCE HOMES 1, LLC

Practice address

3641 28TH Ave S Unit 1
Minneapolis, MN 55406-2515

Phone

(612) 940-2104

NPI assigned

Mar 25, 2024

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark Caleb Globus

Title

Chief Manager

Phone

(612) 940-2104

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1711324800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711324800000",
    "number": "1356191928",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1650 W END BLVD STE 100",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554165369",
            "telephone_number": "612-940-2104"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3641 28TH AVE S UNIT 1",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554062515",
            "telephone_number": "612-940-2104"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVENANCE HOMES 1, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-03-25",
        "last_updated": "2024-03-25",
        "certification_date": "2024-03-25",
        "status": "A",
        "authorized_official_last_name": "GLOBUS",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "CALEB",
        "authorized_official_title_or_position": "CHIEF MANAGER",
        "authorized_official_telephone_number": "612-940-2104"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in Minneapolis, MN
• Providers in Minneapolis, MN by specialty
• Assisted Living Facility in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.