Provider Demographics
NPI:1306599667
Name:MTC SENIOR RESIDENCE
Entity type:Organization
Organization Name:MTC SENIOR RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-434-2389
Mailing Address - Street 1:2600 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1419
Mailing Address - Country:US
Mailing Address - Phone:651-434-2389
Mailing Address - Fax:
Practice Address - Street 1:1702 ABELL ST
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55117-2302
Practice Address - Country:US
Practice Address - Phone:651-434-2389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility