Healthcare Provider Details

I. General information

NPI: 1821570219
Provider Name (Legal Business Name): 2195 CENTURY AVENUE SOUTH OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 CENTURY AVE S
WOODBURY MN
55125-2943
US

IV. Provider business mailing address

5900 CLEARWATER DR STE 500
MINNETONKA MN
55343-8961
US

V. Phone/Fax

Practice location:
  • Phone: 651-459-1400
  • Fax:
Mailing address:
  • Phone: 952-241-8211
  • Fax: 612-360-2331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATE RYG
Title or Position: CLINICAL REIMBURSEMENT MANAGER
Credential:
Phone: 763-486-9187