Basic Information
| Provider Information | |||||||||
| NPI: | 1629401138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLA AT OSSEO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE VILLA AT OSSEO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | OSSEO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553691603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634253939 | ||||||||
| FaxNumber: | 7634242777 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | OSSEO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553691603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634253939 | ||||||||
| FaxNumber: | 7634242777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2013 | ||||||||
| LastUpdateDate: | 08/20/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEEHAN | ||||||||
| AuthorizedOfficialFirstName: | FRANCES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ATTORNEY | ||||||||
| AuthorizedOfficialTelephone: | 3125212467 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ESQ. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 354043000 | 05 | MN | MEDICAID |