Provider Demographics
NPI:1518383744
Name:VSSA BOUTWELLS LANDING,LLC
Entity Type:Organization
Organization Name:VSSA BOUTWELLS LANDING,LLC
Other - Org Name:BOUTWELLS LANDING
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-631-6120
Mailing Address - Street 1:5600 NORWICH PKWY
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6482
Mailing Address - Country:US
Mailing Address - Phone:651-275-5000
Mailing Address - Fax:
Practice Address - Street 1:5600 NORWICH PKWY
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-6482
Practice Address - Country:US
Practice Address - Phone:651-275-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN359577310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA926608200OtherUMPI