Provider Demographics
NPI:1063279834
Name:NEW LIFE HOME LLC
Entity type:Organization
Organization Name:NEW LIFE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIBALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-329-5751
Mailing Address - Street 1:15300 DUNDEE CT
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5887
Mailing Address - Country:US
Mailing Address - Phone:612-441-2030
Mailing Address - Fax:612-545-1758
Practice Address - Street 1:15300 DUNDEE CT
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-5887
Practice Address - Country:US
Practice Address - Phone:612-441-2030
Practice Address - Fax:612-545-1758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances