Provider Demographics
NPI:1942728662
Name:BROOKSIDE SENIOR LIVING
Entity Type:Organization
Organization Name:BROOKSIDE SENIOR LIVING
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 1:7171 OHMS LN
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2142
Mailing Address - Country:US
Mailing Address - Phone:952-855-5041
Mailing Address - Fax:612-800-5311
Practice Address - Street 1:804 BENSON RD
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1307
Practice Address - Country:US
Practice Address - Phone:612-238-5231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility