Provider Demographics
NPI:1427183961
Name:SENIOR CARE WOODBURY, LLC
Entity Type:Organization
Organization Name:SENIOR CARE WOODBURY, LLC
Other - Org Name:WOODBURY VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-431-7932
Mailing Address - Street 1:7012 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7012 LAKE RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55125-2433
Practice Address - Country:US
Practice Address - Phone:651-735-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
MN332432314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7122682OtherMEDICA
MN8764WOOtherBCBS
MN696740000Medicaid
MNNH0133OtherUCARE