=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962921924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MW MINNETONKA OPERATING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2017
-----------------------------------------------------
Last Update Date | 10/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 PAUL PARKWAY NE
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-219-1733
-----------------------------------------------------
Fax | 763-755-6400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 SPRING STREET SUITE 205
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-595-6064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ROBERT SWEET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-595-6064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------