Basic Information
| Provider Information | |||||||||
| NPI: | 1104323773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW WESTERN MANOR COMPANY LIMITED PARTNERSHIP | ||||||||
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| OtherOrganizationName: | AUTUMN GLEN SENIOR LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 HAZELTINE BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553181070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126181682 | ||||||||
| FaxNumber: | 9523618060 | ||||||||
| Practice Location | |||||||||
| Address1: | 3715 COON RAPIDS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637724492 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | WEICHERT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9523618000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 381474 | MN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.