=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962177444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKSIDE SENIOR LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2021
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 BENSON RD
-----------------------------------------------------
City | MONTEVIDEO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56265-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-855-5041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 BENSON RD
-----------------------------------------------------
City | MONTEVIDEO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56265-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-855-5041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF REIMBURSEMENT
-----------------------------------------------------
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 |
-----------------------------------------------------