Provider Demographics
NPI:1659795300
Name:EAGLE CREST SENIOR HOUSING, LLC
Entity Type:Organization
Organization Name:EAGLE CREST SENIOR HOUSING, LLC
Other - Org Name:EAGLECREST
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
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 1:2945 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1338
Mailing Address - Country:US
Mailing Address - Phone:651-628-3000
Mailing Address - Fax:
Practice Address - Street 1:2945 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1338
Practice Address - Country:US
Practice Address - Phone:651-628-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN357428310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA402472100OtherUMPI