Provider Demographics
NPI:1134441827
Name:EBENEZER LAKES ASSISTED LIVING
Entity type:Organization
Organization Name:EBENEZER LAKES ASSISTED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CAMPUS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KARI
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-982-6228
Mailing Address - Street 1:25565 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8053
Mailing Address - Country:US
Mailing Address - Phone:651-982-6228
Mailing Address - Fax:651-466-0714
Practice Address - Street 1:25565 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8053
Practice Address - Country:US
Practice Address - Phone:651-982-6228
Practice Address - Fax:651-466-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN345526310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA660928700Medicare UPIN