Provider Demographics
NPI:1124103569
Name:COUNTRY MEADOWS OF MILACA, INC.
Entity type:Organization
Organization Name:COUNTRY MEADOWS OF MILACA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR 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 1:7485 OFFICE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3690
Mailing Address - Country:US
Mailing Address - Phone:952-259-4485
Mailing Address - Fax:952-259-4498
Practice Address - Street 1:740 2ND ST. SE
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-0157
Practice Address - Country:US
Practice Address - Phone:320-983-2185
Practice Address - Fax:320-983-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332815310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN896487100Medicaid