Provider Demographics
NPI:1699142372
Name:512 49TH AVENUE NORTH, LLC
Entity type:Organization
Organization Name:512 49TH AVENUE NORTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SERGEI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHVETZOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-537-5700
Mailing Address - Street 1:12900 WHITEWATER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9407
Mailing Address - Country:US
Mailing Address - Phone:763-537-5700
Mailing Address - Fax:763-537-9200
Practice Address - Street 1:512 49TH AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-3621
Practice Address - Country:US
Practice Address - Phone:612-529-7747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-28
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility