Five Star Living of Brainerd, LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

333812 Issued in MN

Legal business name

FIVE STAR LIVING OF BRAINERD, LLC

Doing business as

Diamond Willow

Practice address

14398 Grand Oaks Drive
Baxter, MN 56425

Phone

(218) 625-2316

Fax

(218) 625-2338

NPI assigned

Apr 12, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Ms. Lynn Gevik, RN

Title

Coo

Phone

(218) 625-2316

Specialties & licenses 1

Addresses

Other names 1

• Diamond Willow Doing business as

Tax ID family

Diamond Willow2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Five Star Living of Brainerd, LLC

  dba Diamond Willow

  • Assisted Living Facility
  • Baxter, MN
  • NPI 1093842247
  NPD tax ID

Locations

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

{
    "created_epoch": "1176336000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1508080631",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 E SUPERIOR ST",
            "address_2": "SUITE 508",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558022007",
            "telephone_number": "218-625-2316",
            "fax_number": "218-625-2338"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14398 GRAND OAKS DRIVE",
            "city": "BAXTER",
            "state": "MN",
            "postal_code": "56425",
            "telephone_number": "218-625-2316",
            "fax_number": "218-625-2338"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FIVE STAR LIVING OF BRAINERD, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-12",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "GEVIK",
        "authorized_official_first_name": "LYNN",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "218-625-2316",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "MN",
            "license": "333812",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Diamond Willow",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Emily Faye Fitch
• Jennifer Rose Fitch
• Nicholas Gordon Fitch
• Shelby Irene Fitch
• Five Star Living of Brainerd, LLC (Diamond Willow)
• Cassandra Nicole Flach, PT, DPT
• Melissa Marylin Fleischhacker
• Georgia Kathleen Forsman
• Jeanni R Foss, D.D.S.
• Miranda Lynne Frame

• Assisted Living Facility in Baxter, MN
• Providers in Baxter, 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 Aug 22, 2020; 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.