=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285589689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITEFISH AT THE LAKES OPCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2026
-----------------------------------------------------
Last Update Date | 03/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35625 OSTLUND AVE
-----------------------------------------------------
City | CROSSLAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56442-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-210-0770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3520 E RIVER RD NE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55906-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP BUSINESS STRATEGY
-----------------------------------------------------
Name | JORDAN RYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-251-6356
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------