Provider Demographics
NPI:1558366146
Name:LEGACY SENIOR SERVICES
Entity Type:Organization
Organization Name:LEGACY SENIOR SERVICES
Other - Org Name:TRAVERSE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-695-5618
Mailing Address - Street 1:303 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MN
Mailing Address - Zip Code:56296-1740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 7TH ST S
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MN
Practice Address - Zip Code:56296-1740
Practice Address - Country:US
Practice Address - Phone:320-563-8124
Practice Address - Fax:320-563-4133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00669314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN145240100Medicaid
MN9264TROtherBCBS OF MINNESOTA
MN245585Medicare ID - Type UnspecifiedMEDICARE NUMBER