Provider Demographics
NPI:1962776187
Name:COVENTRY SENIOR LIVING OF MAHTOMEDI, LLC
Entity type:Organization
Organization Name:COVENTRY SENIOR LIVING OF MAHTOMEDI, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOUSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAWYER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:651-528-8442
Mailing Address - Street 1:720 MAHTOMEDI AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1673
Mailing Address - Country:US
Mailing Address - Phone:651-528-8442
Mailing Address - Fax:651-756-8240
Practice Address - Street 1:720 MAHTOMEDI AVE
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1673
Practice Address - Country:US
Practice Address - Phone:651-528-8442
Practice Address - Fax:651-756-8240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SENIOR PROPERTIES OF MAHTOMEDI, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN355819251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health