Provider Demographics
NPI:1114343332
Name:PHS/CHANHASSEN,INC.
Entity Type:Organization
Organization Name:PHS/CHANHASSEN,INC.
Other - Org Name:SUMMERWOOD OF CHANHASSEN
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-631-6120
Mailing Address - Street 1:525 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8364
Mailing Address - Country:US
Mailing Address - Phone:952-294-5500
Mailing Address - Fax:
Practice Address - Street 1:525 LAKE DR
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-8364
Practice Address - Country:US
Practice Address - Phone:952-294-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN358746310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA697445000OtherUMPI