Provider Demographics
NPI:1154506368
Name:PARK TERRACE ASSISTED LIVING, INC.
Entity Type:Organization
Organization Name:PARK TERRACE ASSISTED LIVING, INC.
Other - Org Name:PARK VIEW ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:SEELOCHANI
Authorized Official - Middle Name:
Authorized Official - Last Name:STADTHERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-855-5041
Mailing Address - Street 1:613 MONTROSE BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1384
Mailing Address - Country:US
Mailing Address - Phone:763-684-4866
Mailing Address - Fax:763-682-6855
Practice Address - Street 1:613 MONTROSE BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1384
Practice Address - Country:US
Practice Address - Phone:763-684-4866
Practice Address - Fax:763-682-6855
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELIM CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-07
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN337997310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN766470000Medicaid