Provider Demographics
NPI:1295008787
Name:NINE MILE CATERED LIVING
Entity Type:Organization
Organization Name:NINE MILE CATERED LIVING
Other - Org Name:NINE MILE CREEK SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOUSING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-888-0731
Mailing Address - Street 1:2301 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-5810
Mailing Address - Country:US
Mailing Address - Phone:952-888-0731
Mailing Address - Fax:952-884-2191
Practice Address - Street 1:2301 VILLAGE LN
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-5810
Practice Address - Country:US
Practice Address - Phone:952-888-0731
Practice Address - Fax:952-884-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN353396310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility