Provider Demographics
NPI:1972936714
Name:NASRA S GONJOBE
Entity type:Organization
Organization Name:NASRA S GONJOBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ABDI
Authorized Official - Middle Name:G
Authorized Official - Last Name:GONJOBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-230-9300
Mailing Address - Street 1:1312 BURKE CIR E
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-3450
Mailing Address - Country:US
Mailing Address - Phone:651-230-9300
Mailing Address - Fax:651-756-1696
Practice Address - Street 1:1312 BURKE CIR E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-3450
Practice Address - Country:US
Practice Address - Phone:651-230-9300
Practice Address - Fax:651-756-1696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1056572-2-AFC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home