1629708524 NPI number — SUITE LIVING SENIOR CARE OF LAKEVILLE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629708524 NPI number — SUITE LIVING SENIOR CARE OF LAKEVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUITE LIVING SENIOR CARE OF LAKEVILLE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629708524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 BUERKLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-5245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-964-1092
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20949 KEOKUK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-770-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
MCELWAIN
Authorized Official First Name:
AUDREY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
651-770-2273

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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