Basic Information
| Provider Information | |||||||||
| NPI: | 1891789434 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVIV HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BERKSHIRE RESIDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4509 MINNETONKA BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9522595224 | ||||||||
| FaxNumber: | 9529205207 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | OSSEO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553691603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634253939 | ||||||||
| FaxNumber: | 7634242777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PASELL | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 9522595222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 328130 | MN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 7122708 | 01 | MN | MEDICA | OTHER | 9456BE | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | NH0003 | 01 | MN | UCARE | OTHER |