Provider Demographics
NPI:1497264147
Name:MINNETONKA ASSISTED LIVING AND HOSPICE
Entity Type:Organization
Organization Name:MINNETONKA ASSISTED LIVING AND HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOMACHANARY
Authorized Official - Middle Name:KRISTIE
Authorized Official - Last Name:KUOCH
Authorized Official - Suffix:
Authorized Official - Credentials:CAREGIVER
Authorized Official - Phone:952-405-6960
Mailing Address - Street 1:14667 LAKE STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2926
Mailing Address - Country:US
Mailing Address - Phone:952-405-6960
Mailing Address - Fax:
Practice Address - Street 1:14667 LAKE STREET EXTENSION
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345
Practice Address - Country:US
Practice Address - Phone:952-405-6960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN383702172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN82121568Medicaid