Provider Demographics
NPI:1083962294
Name:IN HOUSE SENIOR SERVICES, LLC
Entity Type:Organization
Organization Name:IN HOUSE SENIOR SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WECKWERTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-200-8029
Mailing Address - Street 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-243-8999
Mailing Address - Fax:612-869-3473
Practice Address - Street 1:6625 LYNDALE AVE S STE 105
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2673
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:612-869-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 231H00000X
MN631213E00000X, 213E00000X
MN7496231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083962294Medicaid
MN1083962294Medicaid
MNC09267OtherMEDICARE PTAN