Healthcare Provider Details

I. General information

NPI: 1548510126
Provider Name (Legal Business Name): LILYDALE SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 SIBLEY MEMORIAL HWY
SAINT PAUL MN
55118-3601
US

IV. Provider business mailing address

2285 WATERS DR
MENDOTA HEIGHTS MN
55120-1363
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-6853
  • Fax:
Mailing address:
  • Phone: 651-454-4801
  • Fax:

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: LANCE E LEMIEUX
Title or Position: PRESIDENT
Credential:
Phone: 651-454-4801