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NPI Code Detail

MEDICARE: 512 49TH AVENUE NORTH, LLC

MEDICARE: 512 49TH AVENUE NORTH, 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
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1699142372
Entity Type Code : Organization
Provider Name (Legal Business Name) : 512 49TH AVENUE NORTH, LLC
Provider Business Mailing Address
First Line : 12900 WHITEWATER DR STE 201
Second Line :
City : HOPKINS
State : MN
Zip : 55343-9407
Country : US
Telephone Number : 763-537-5700
Fax Number : 763-537-9200
Provider Business Practice Location Address
First Line : 512 49TH AVE N
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55430-3621
Country : US
Telephone Number : 612-529-7747
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : SERGEI SHVETZOFF
Credential :
Telephone Number : 763-537-5700
Provider Enumeration Date : 08/28/2015
Last Update Date : 11/06/2019

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