Healthcare Provider Details

I. General information

NPI: 1053225698
Provider Name (Legal Business Name): CITADEL MAHTOMEDI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 CLEARWATER DR STE 500
MINNETONKA MN
55343-8961
US

IV. Provider business mailing address

5900 CLEARWATER DR STE 500
MINNETONKA MN
55343-8961
US

V. Phone/Fax

Practice location:
  • Phone: 763-486-9187
  • Fax: 612-360-2331
Mailing address:
  • Phone: 763-486-9187
  • Fax: 612-360-2331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: KATE RYG
Title or Position: MEDICAID SERVICES MANAGER
Credential:
Phone: 763-486-9187