Basic Information
Provider Information | |||||||||
NPI: | 1366817819 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MSL-EBT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EARLE BROWN TERRACE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2568 | ||||||||
Address2: |   | ||||||||
City: | HICKORY | ||||||||
State: | NC | ||||||||
PostalCode: | 286032568 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8283225535 | ||||||||
FaxNumber: | 8283268115 | ||||||||
Practice Location | |||||||||
Address1: | 6100 SUMMIT DR N | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN CENTER | ||||||||
State: | MN | ||||||||
PostalCode: | 554302151 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635606829 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2015 | ||||||||
LastUpdateDate: | 12/09/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TREFZGER | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8283225535 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 375200 | MN | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.