24D2107005 CLIA NUMBER - EAGLE STREET ASSISTIVE LIVING

Laboratory Demographics

CLIA Number: 24D2107005

Facility Name: EAGLE STREET ASSISTIVE LIVING

Facility Address:
12009 EAGLE STREET NW
COON RAPIDS, MN
ZIP 55448
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Facility Phone Number: 763 862-1627

Facility Type: Assisted Living Facility

Certificate Type: Waiver

NPI Number: 1235414483

Taxonomy: 310400000X - Assisted Living Facility
A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being.

CLIA Record

Field Name	Field Value
CLIA Number	24D2107005
LAB Type	Assisted Living Facility
Facility Name	EAGLE STREET ASSISTIVE LIVING
Street	12009 EAGLE STREET NW
City	COON RAPIDS
State	MN
ZIP	55448
Phone	763 862-1627
CertificateType	4
CertificateEffectiveDate	1/5/2024
CertificateExpirationDate	1/4/2026
FacilityType	Waiver

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