Provider Demographics
NPI:1457837668
Name:MIDWEST GROUP LIVING INC.
Entity Type:Organization
Organization Name:MIDWEST GROUP LIVING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HESEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-222-1111
Mailing Address - Street 1:415 CEDAR AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1011
Mailing Address - Country:US
Mailing Address - Phone:952-457-3802
Mailing Address - Fax:612-454-2629
Practice Address - Street 1:3552 1ST AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4509
Practice Address - Country:US
Practice Address - Phone:952-457-3802
Practice Address - Fax:612-454-2629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========Medicaid