Healthcare Provider Details

I. General information

NPI: 1437796976
Provider Name (Legal Business Name): SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7949 BRUNSWICK AVE N
BROOKLYN PARK MN
55443-2037
US

IV. Provider business mailing address

18573 70TH AVE N
MAPLE GROVE MN
55311-2261
US

V. Phone/Fax

Practice location:
  • Phone: 763-400-1819
  • Fax:
Mailing address:
  • Phone: 763-400-1819
  • Fax: 763-343-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ANKUR CHOPRA
Title or Position: OWNER
Credential:
Phone: 763-400-1819