Provider Demographics
NPI:1174511828
Name:LAKE RIDGE CARE CENTER OF BUFFALO, INC.
Entity Type:Organization
Organization Name:LAKE RIDGE CARE CENTER OF BUFFALO, INC.
Other - Org Name:
Other - Org Type:
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 1:310 LAKE BLVD S
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1456
Mailing Address - Country:US
Mailing Address - Phone:763-682-1434
Mailing Address - Fax:763-682-6419
Practice Address - Street 1:310 LAKE BLVD S
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1456
Practice Address - Country:US
Practice Address - Phone:763-682-1434
Practice Address - Fax:763-682-6419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327290314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN327290OtherMINNESOTA STATE LICENSE
MN066663700Medicaid