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General NPI Number Information
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NPI Number | 1497264147
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Entity Type | Organization
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Legal Business Name | MINNETONKA ASSISTED LIVING AND HOSPICE
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Dates
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Enumeration Date | 09/26/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 14667 LAKE STREET EXTENSION
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City | MINNETONKA
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State | MN
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Zip | 55345
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Country | US
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Telephone | 952-405-6960
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Fax |
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Provider Business Mailing Address
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Address Line | 14667 LAKE STREET EXT
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City | MINNETONKA
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State | MN
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Zip | 55345-2926
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Country | US
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Telephone | 952-405-6960
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SOMACHANARY KRISTIE KUOCH
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Credential | CAREGIVER
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Telephone | 952-405-6960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | 383702
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License Number State | MN
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