Provider Demographics
NPI:1891926838
Name:NORTHSIDE LIFE CARE CENTER
Entity Type:Organization
Organization Name:NORTHSIDE LIFE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LORSUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-522-6589
Mailing Address - Street 1:4367 THOMAS AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1005
Mailing Address - Country:US
Mailing Address - Phone:912-522-6589
Mailing Address - Fax:
Practice Address - Street 1:4367 THOMAS AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-1005
Practice Address - Country:US
Practice Address - Phone:912-522-6589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable