Provider Demographics
NPI:1003563545
Name:PHS-WHITE BEAR LAKE LLC
Entity Type:Organization
Organization Name:PHS-WHITE BEAR LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-631-6120
Mailing Address - Street 1:2845 HAMLINE AVE N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-7127
Mailing Address - Country:US
Mailing Address - Phone:651-631-6450
Mailing Address - Fax:651-631-6122
Practice Address - Street 1:4650 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-3200
Practice Address - Country:US
Practice Address - Phone:651-631-6100
Practice Address - Fax:651-631-6122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility