=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336505296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MW MINNETONKA OPERATING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2016
-----------------------------------------------------
Last Update Date | 01/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14505 MINNETONKA DR
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-712-0118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 SPRING ST STE 205
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-595-6064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTORIZED OFFICIAL
-----------------------------------------------------
Name | ROBERT SWEET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-595-6064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------