Provider Demographics
NPI:1356686836
Name:MINNESOTA SENIOR LIVING LLC
Entity Type:Organization
Organization Name:MINNESOTA SENIOR LIVING LLC
Other - Org Name:WATERFORD MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF STRATEGIC PARTNERSHIPS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-559-6325
Mailing Address - Street 1:915 118TH AVE SE
Mailing Address - Street 2:110
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3819
Mailing Address - Country:US
Mailing Address - Phone:425-559-6301
Mailing Address - Fax:425-559-6302
Practice Address - Street 1:6288 LOUISIANA CT N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-2550
Practice Address - Country:US
Practice Address - Phone:763-537-3382
Practice Address - Fax:763-535-2075
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESBYTERIAN RETIREMENT COMMUNITIES NORTHWEST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-10
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility