MEDICARE: EDINA 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1992244313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDINA SENIOR LIVING LLC

Provider Business Mailing Address
First Line	:	6500 FRANCE AVE S
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1700
Country	:	US
Telephone Number	:	952-848-8888
Fax Number	:	952-848-8899

Provider Business Practice Location Address
First Line	:	6500 FRANCE AVE S
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-1700
Country	:	US
Telephone Number	:	952-848-8888
Fax Number	:	952-848-8899

Authorized Official
Title or Position	:	SECRETARY OF THE BOARD
Name	:	JONATHON LUNDBERG
Credential	:
Telephone Number	:	612-874-3476

Provider Enumeration Date	:	02/17/2017
Last Update Date	:	02/17/2017

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