Provider Demographics
NPI:1710186838
Name:AUGUSTANA DASSEL LAKESIDE COMMUNITY HOME, LLC
Entity Type:Organization
Organization Name:AUGUSTANA DASSEL LAKESIDE COMMUNITY HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:SEELOCHANI
Authorized Official - Middle Name:
Authorized Official - Last Name:STADTHERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-855-5041
Mailing Address - Street 1:439 WILLIAM AVE E
Mailing Address - Street 2:PO BOX 383
Mailing Address - City:DASSEL
Mailing Address - State:MN
Mailing Address - Zip Code:55325-1102
Mailing Address - Country:US
Mailing Address - Phone:320-275-3308
Mailing Address - Fax:
Practice Address - Street 1:439 WILLIAM AVE E
Practice Address - Street 2:
Practice Address - City:DASSEL
Practice Address - State:MN
Practice Address - Zip Code:55325-1102
Practice Address - Country:US
Practice Address - Phone:320-275-3308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN335267314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN314182000Medicaid
245533Medicare Oscar/Certification