MEDICARE: SOUTHSIDE LIFE CARE CENTER

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1982879771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE LIFE CARE CENTER

Provider Business Mailing Address
First Line	:	4105 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3144
Country	:	US
Telephone Number	:	612-823-0301
Fax Number	:	612-823-0775

Provider Business Practice Location Address
First Line	:	4105 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3144
Country	:	US
Telephone Number	:	612-823-0301
Fax Number	:	612-823-0775

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	KIMBERLY RYNDERS
Credential	:
Telephone Number	:	612-823-0301

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	04/23/2008

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