Basic Information
| Provider Information | |||||||||
| NPI: | 1760427488 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIRAMONT POINTE | ||||||||
| 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: | 11520 SE SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970154306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036981600 | ||||||||
| FaxNumber: | 5036520168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOODMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9523618000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | NO NUMBER ASSIGNED | OR | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.