Provider Demographics
NPI:1164177630
Name:LILLY J'S HOUSING & SERVICES L.L.C.
Entity Type:Organization
Organization Name:LILLY J'S HOUSING & SERVICES L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NATALEE
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:SUCKOO
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:612-458-4545
Mailing Address - Street 1:111 63 1/2 WAY NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4819
Mailing Address - Country:US
Mailing Address - Phone:612-458-4545
Mailing Address - Fax:763-205-2479
Practice Address - Street 1:111 63 1/2 WAY NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4819
Practice Address - Country:US
Practice Address - Phone:612-458-4545
Practice Address - Fax:763-205-2479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-14
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility