Provider Demographics
NPI:1851599021
Name:SENIOR CARE PROVIDENCE, LLC
Entity Type:Organization
Organization Name:SENIOR CARE PROVIDENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-431-7932
Mailing Address - Street 1:3720 23RD AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3720 23RD AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3010
Practice Address - Country:US
Practice Address - Phone:612-724-5495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328868314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN428093639OtherMHP
MN8810NIOtherBCBS
MNNH0131OtherUCARE
MN62845OtherHPARTNERS
MN608719100Medicaid
MN7100377OtherMEDICA
MN7122705OtherMEDICA