24D0401704 CLIA NUMBER - GRAND AVENUE REST HOME

Laboratory Demographics

CLIA Number: 24D0401704

Facility Name: GRAND AVENUE REST HOME

Facility Address:
3956 GRAND AVE S
MINNEAPOLIS, MN
ZIP 55409
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Facility Phone Number: 612 824-1434

Facility Type: Skilled Nursing Facility/Nursing Facility

Certificate Type: Waiver

NPI Number: 1932196235

Taxonomy: 310500000X - Intermediate Care Facility, Mental Illness
A nursing facility that provides an intermediate level of nursing care to individuals whose functional abilities are significantly compromise by mental illness.

CLIA Record

Field Name	Field Value
CLIA Number	24D0401704
LAB Type	Skilled Nursing Facility/Nursing Facility
Facility Name	GRAND AVENUE REST HOME
Street	3956 GRAND AVE S
City	MINNEAPOLIS
State	MN
ZIP	55409
Phone	612 824-1434
CertificateType	4
CertificateEffectiveDate	9/1/2022
CertificateExpirationDate	8/31/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024