MEDICARE: MINNESOTA SENIOR LIVING 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	:	1356686836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA SENIOR LIVING LLC

Provider Business Mailing Address
First Line	:	915 118TH AVE SE
Second Line	:	110
City	:	BELLEVUE
State	:	WA
Zip	:	98005-3819
Country	:	US
Telephone Number	:	425-559-6301
Fax Number	:	425-559-6302

Provider Business Practice Location Address
First Line	:	6288 LOUISIANA CT N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-2550
Country	:	US
Telephone Number	:	763-537-3382
Fax Number	:	763-535-2075

Authorized Official
Title or Position	:	DIRECTOR OF STRATEGIC PARTNERSHIPS
Name	:	MARK MULLEN
Credential	:
Telephone Number	:	425-559-6325

Provider Enumeration Date	:	12/10/2012
Last Update Date	:	04/27/2017

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