GRAND AVENUE RESIDENCE
NPI 1932196235
Intermediate Care Facility, Mental Illness in Minneapolis, MN

Q: What is Grand Avenue Rest Home Inc's NPI number?

The NPI number for Grand Avenue Rest Home Inc is 1932196235. It was assigned to this organization in the NPPES registry on October 1, 2005. The provider is also known as Grand Avenue Residence.

Q: What is Grand Avenue Rest Home Inc's specialty?

The primary specialty registered for this NPI is Intermediate Care Facility, Mental Illness with taxonomy code 310500000X.

Active since October 01, 2005CLIA 24D0401704 · Waiver

3956 GRAND AVE S, MINNEAPOLIS, MN 55409(612) 824-1434(612) 824-2219 Get Directions Write a Review

NPPES record last updated: August 22, 2020. Verified against the NPPES registry weekly; last sync: August 16, 2026.

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About Grand Avenue Residence NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

GRAND AVENUE RESIDENCE (NPI 1932196235) is a healthcare organization registered as an intermediate care facility, mental illness in Minneapolis, Minnesota and active in the NPI registry since October 2005. The organization holds a CLIA Waiver certificate valid through August 31, 2026 and lists Nancy Lynn Soderbeck, Acting Administrator, as its authorized official.

NPPES Registry Identity

NPI1932196235

Entity TypeOrganization

Primary Taxonomy310500000X

Legal Business NameGRAND AVENUE REST HOME INC

Location Address3956 GRAND AVE SMinneapolis, MN 55409-1535

Mailing Address3956 Grand Ave SMinneapolis, MN 55409-1535 · (612) 824-1434 · Fax (612) 824-2219

Phone(612) 824-1434

Fax(612) 824-2219

Organization SubpartNo

Authorized OfficialNancy Lynn SoderbeckActing Administrator · (612) 824-1434

Enumeration DateOctober 1, 2005

Last NPPES UpdateAugust 22, 2020

✔ NPI 1932196235 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyIntermediate Care Facility, Mental IllnessNursing & Custodial Care Facilities

Taxonomy Code310500000X

Definition

A nursing facility that provides an intermediate level of nursing care to individuals whose functional abilities are significantly compromise by mental illness.

3956 GRAND AVE S, Minneapolis, MN 55409

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Other Names 1

Other NameGrand Avenue Residence

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 24D0401704

Grand Avenue Rest Home · Minneapolis, MN

Active · expires Aug 31, 2026

CLIA Number24D0401704

Laboratory TypeSkilled Nursing Facility/Nursing Facility

Certificate Effective DateSeptember 1, 2024

Certificate Expiration DateAugust 31, 2026

Laboratory DirectorBernice Ngwa

Laboratory Phone(612) 824-1434

Laboratory LocationGrand Avenue Rest Home3956 Grand Ave S, Minneapolis, MN 55409

CLIA data matches this NPI record on: Address Name Phone

This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Grand Avenue Rest Home Inc's NPI number?

The NPI number for Grand Avenue Rest Home Inc is 1932196235. It was assigned to this organization in the NPPES registry on October 1, 2005. The provider is also known as Grand Avenue Residence.

Where is Grand Avenue Rest Home Inc located?

Grand Avenue Rest Home Inc is located at 3956 Grand Ave S, Minneapolis, MN 55409. The listed phone number is (612) 824-1434.

What is Grand Avenue Rest Home Inc's specialty?

The primary specialty registered for this NPI is Intermediate Care Facility, Mental Illness with taxonomy code 310500000X.

Does Grand Avenue Rest Home Inc hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 24D0401704) is associated with this NPI, valid through August 31, 2026. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Grand Avenue Rest Home Inc was last updated on August 22, 2020. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 5 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.