MEDICARE: 2790 ELM TREE HILL OPCO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1275422644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	2790 ELM TREE HILL OPCO LLC

Provider Business Mailing Address
First Line	:	5900 CLEARWATER DR STE 500
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55343-8961
Country	:	US
Telephone Number	:	763-486-9187
Fax Number	:	612-360-2331

Provider Business Practice Location Address
First Line	:	2790 ELM TREE HL
Second Line	:
City	:	HOWARD
State	:	WI
Zip	:	54313-3004
Country	:	US
Telephone Number	:	920-489-8600
Fax Number	:	612-360-2331

Authorized Official
Title or Position	:	CLINICAL REIMBURSEMENT MANAGER
Name	:	KATE RYG
Credential	:
Telephone Number	:	763-486-9187

Provider Enumeration Date	:	07/01/2025
Last Update Date	:	09/22/2025

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