Provider Demographics
NPI:1366208704
Name:PLEASANT LIGHT LLC
Entity type:Organization
Organization Name:PLEASANT LIGHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSPHAT
Authorized Official - Middle Name:NYAMBATI
Authorized Official - Last Name:OMARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-500-8335
Mailing Address - Street 1:14501 GRAND AVE APT 529
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6604
Mailing Address - Country:US
Mailing Address - Phone:651-500-8335
Mailing Address - Fax:
Practice Address - Street 1:7765 DALEVIEW DR
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3330
Practice Address - Country:US
Practice Address - Phone:651-500-8335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLEASANT LIGHT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances