1972947851 NPI number — VILLA AT OSSEO LLC

Table of content: (NPI 1972947851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972947851 NPI number — VILLA AT OSSEO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLA AT OSSEO LLC
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:
1972947851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3701 W LUNT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLNWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60712-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-440-2660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 2ND STREET NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSSEO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-425-3939
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ISRAEL
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
847-692-1155

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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