=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942728662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKSIDE SENIOR LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2017
-----------------------------------------------------
Last Update Date | 11/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 BENSON RD
-----------------------------------------------------
City | MONTEVIDEO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56265-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-238-5231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7171 OHMS LN
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-855-5041
-----------------------------------------------------
Fax | 612-800-5311
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE VP OF REVENUE CYCLE MGMT
-----------------------------------------------------
Name | SEELOCHANI STADTHERR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-855-5041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------