Provider Demographics
NPI:1720593353
Name:MINNESOTA SENIOR LIVING LLC
Entity Type:Organization
Organization Name:MINNESOTA SENIOR LIVING LLC
Other - Org Name:MERIDIAN MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:WITSCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-202-1702
Mailing Address - Street 1:915 118TH AVE SE STE 110
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3875
Mailing Address - Country:US
Mailing Address - Phone:425-559-6301
Mailing Address - Fax:
Practice Address - Street 1:163 WAYZATA BLVD W
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1562
Practice Address - Country:US
Practice Address - Phone:952-473-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA SENIOR LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN381390310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility