Healthcare Provider Details

I. General information

NPI: 1871421222
Provider Name (Legal Business Name): PROSPERITY CARE RESIDENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 PROSPERITY AVE
SAINT PAUL MN
55106-2124
US

IV. Provider business mailing address

1233 PROSPERITY AVE
SAINT PAUL MN
55106-2124
US

V. Phone/Fax

Practice location:
  • Phone: 651-666-5348
  • Fax: 844-444-1256
Mailing address:
  • Phone: 651-666-5348
  • Fax: 844-444-1256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL CHERWAYIA THAO
Title or Position: OWNER / ADMINISTRATOR
Credential:
Phone: 612-759-2379