Healthcare Provider Details

I. General information

NPI: 1073796322
Provider Name (Legal Business Name): LIFE SENIOR CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28347 112TH ST NW
ZIMMERMAN MN
55398-4307
US

IV. Provider business mailing address

8503 178TH LN NE
FOREST LAKE MN
55025-8351
US

V. Phone/Fax

Practice location:
  • Phone: 763-350-6369
  • Fax:
Mailing address:
  • Phone: 651-464-6167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMN

VIII. Authorized Official

Name: MARGERY ANN VETSCH-PETERSON
Title or Position: RN CARE MANAGER
Credential: RN
Phone: 763-350-6369