Provider Demographics
NPI:1710018122
Name:NORTHLAND ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:NORTHLAND ASSISTED LIVING LLC
Other - Org Name:NORTHLAND VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SERTICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-723-4040
Mailing Address - Street 1:202 W SUPERIOR ST
Mailing Address - Street 2:SUITE 610
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1936
Mailing Address - Country:US
Mailing Address - Phone:218-723-4040
Mailing Address - Fax:218-723-4048
Practice Address - Street 1:22027 420TH STREET
Practice Address - Street 2:
Practice Address - City:MCGREGOR
Practice Address - State:MN
Practice Address - Zip Code:55760-5963
Practice Address - Country:US
Practice Address - Phone:218-768-3356
Practice Address - Fax:218-768-3379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN335311310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility