Provider Demographics
NPI:1760607097
Name:SENIOR CARE WOODBURY, LLC
Entity Type:Organization
Organization Name:SENIOR CARE WOODBURY, LLC
Other - Org Name:WOODBURY VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-286-1170
Mailing Address - Street 1:7008 LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3824
Mailing Address - Country:US
Mailing Address - Phone:651-731-5501
Mailing Address - Fax:
Practice Address - Street 1:7008 LAKE ROAD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3824
Practice Address - Country:US
Practice Address - Phone:651-731-5501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENIOR CARE WOODBURY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4980442Other4980442
MN796108100Medicaid
MN131445OtherUCARE
MN115925OtherHEALTHPARTNERS