Healthcare Provider Details

I. General information

NPI: 1982879771
Provider Name (Legal Business Name): SOUTHSIDE LIFE CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 CHICAGO AVE
MINNEAPOLIS MN
55407-3144
US

IV. Provider business mailing address

4105 CHICAGO AVE
MINNEAPOLIS MN
55407-3144
US

V. Phone/Fax

Practice location:
  • Phone: 612-823-0301
  • Fax: 612-823-0775
Mailing address:
  • Phone: 612-823-0301
  • Fax: 612-823-0775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY RYNDERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-823-0301