Healthcare Provider Details

I. General information

NPI: 1184737926
Provider Name (Legal Business Name): PHS LAKE MINNETONKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 SHORELINE DR
SPRING PARK MN
55384-8500
US

IV. Provider business mailing address

4527 SHORELINE DR
SPRING PARK MN
55384-8706
US

V. Phone/Fax

Practice location:
  • Phone: 952-471-4001
  • Fax: 651-631-6449
Mailing address:
  • Phone: 952-471-4001
  • Fax: 651-631-6449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7122641
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICA
# 2
Identifier22857
Identifier TypeOTHER
Identifier State
Identifier IssuerHEALTH PARTNERS
# 3
Identifier172043100
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 4
IdentifierNH0041
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerUCARE
# 5
Identifier9625TW
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS

VIII. Authorized Official

Name: MR. MARK MEYER
Title or Position: CFO
Credential:
Phone: 651-631-6102