Healthcare Provider Details

I. General information

NPI: 1710764105
Provider Name (Legal Business Name): SISU LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 03/25/2024
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 2ND AVE NE
SAINT CLOUD MN
56304-4000
US

IV. Provider business mailing address

2107 TROOP DR STE 201
SARTELL MN
56377-4563
US

V. Phone/Fax

Practice location:
  • Phone: 320-292-0366
  • Fax:
Mailing address:
  • Phone: 320-292-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SUMMER A KLENKEN
Title or Position: OWNER & BUSINESS MANAGER
Credential:
Phone: 320-292-0366