Provider Demographics
NPI:1184493124
Name:WILLOW RESIDENCE LLC
Entity type:Organization
Organization Name:WILLOW RESIDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAISA
Authorized Official - Middle Name:YASIN
Authorized Official - Last Name:HUSSEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-913-2975
Mailing Address - Street 1:3208 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2008
Mailing Address - Country:US
Mailing Address - Phone:612-913-2975
Mailing Address - Fax:612-444-8984
Practice Address - Street 1:3208 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-2008
Practice Address - Country:US
Practice Address - Phone:612-913-2975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-01
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility