1124103569 NPI number — COUNTRY MEADOWS OF MILACA, INC.

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 1124103569 NPI number — COUNTRY MEADOWS OF MILACA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRY MEADOWS OF MILACA, INC.
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:
1124103569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7171 OHMS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55439-2142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-855-5041
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 2ND ST. SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILACA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56353-0157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-983-2185
Provider Business Practice Location Address Fax Number:
320-983-2190
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STADTHERR
Authorized Official First Name:
SEELOCHANI
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSOCIATE VP OF REVENUE CYCLE MGMT
Authorized Official Telephone Number:
952-855-5041

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  332815 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 896487100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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