Healthcare Provider Details

I. General information

NPI: 1366817819
Provider Name (Legal Business Name): MSL-EBT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 SUMMIT DR N
BROOKLYN CENTER MN
55430-2151
US

IV. Provider business mailing address

PO BOX 2568
HICKORY NC
28603-2568
US

V. Phone/Fax

Practice location:
  • Phone: 763-560-6829
  • Fax:
Mailing address:
  • Phone: 828-322-5535
  • Fax: 828-326-8115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number375200
License Number StateMN

VIII. Authorized Official

Name: CHARLES E TREFZGER
Title or Position: MANAGER
Credential:
Phone: 828-322-5535