Basic Information
| Provider Information | |||||||||
| NPI: | 1912326489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WATERS EDGE AT WILLOW BROOK | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WATER'S EDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 WOODHILL CT | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073885582 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 AGENCY TRL | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560016936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073885582 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 04/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | BROOKE | ||||||||
| AuthorizedOfficialMiddleName: | AMBER | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5073885582 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 366639 | MN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.