Basic Information
| Provider Information | |||||||||
| NPI: | 1578504437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILHC OF EAGAN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE COMMONS ON MARICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 HAZELTINE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553181009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523618000 | ||||||||
| FaxNumber: | 9523618058 | ||||||||
| Practice Location | |||||||||
| Address1: | 1380 MARICE DR | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551219748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516889999 | ||||||||
| FaxNumber: | 6516887888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | GUSTAFSON | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9523618000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 329867 | MN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 344718900 | 05 | MN | MEDICAID |