Provider Demographics
NPI:1548510126
Name:LILYDALE SENIOR LIVING LLC
Entity type:Organization
Organization Name:LILYDALE SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEMIEUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-454-4801
Mailing Address - Street 1:2285 WATERS DR
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1363
Mailing Address - Country:US
Mailing Address - Phone:651-454-4801
Mailing Address - Fax:
Practice Address - Street 1:949 SIBLEY MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3601
Practice Address - Country:US
Practice Address - Phone:651-454-6853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility