- Enrollment id
- O20080206000538
- Enrollment state
- MN
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1851599021
- Multiple npi flag
- N
- Ccn
- 245271
- Associate id
- 4385732841
- Organization name
- SENIOR CARE PROVIDENCE, LLC
- Doing business as name
- PROVIDENCE PLACE
- Incorporation date
- 2007-06-21
- Incorporation state
- DE
- Organization type structure
- LLC
- Proprietary nonprofit
- N
- Nursing home provider name
- PROVIDENCE PLACE
- Affiliation entity name
- LIFESPARK
- Affiliation entity id
- 316
- Address line 1
- 3720 23RD AVE S
- City
- MINNEAPOLIS
- State
- MN
- Zip code
- 554073010