Ebenezer Lakes Assisted Living
Organization Active NPI Skilled Nursing Facility · Wyoming, MN
NPI 1679916571 · NPPES record last updated Dec 30, 2016
Key facts
- NPI
- 1679916571
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- Legal business name
- EBENEZER LAKES ASSISTED LIVING
- Practice address
- 25565 Fairview Ave
Wyoming, MN 55092-8053 - Phone
- (651) 982-6228
- Fax
- (651) 466-0714
- NPI assigned
- Apr 10, 2013
- Organization subpart
- No
Authorized official
- Name
- Ms. Kari Beth Wilson, LNHA
- Title
- Campus Director
- Phone
- (651) 982-6228
Owners & managing parties with NPI records 3
-
Yasser Chebli, MD
Corporate family (same tax ID) 1
Member of 1
Facilities with the same owner 7
Practitioners 1
-
Yasser Chebli, MD
Affiliated clinicians 2
-
Vanessa Kasper, APRN CNP DNP
Medicare Care Compare: Nursing home
- Listed as
- Meadows on Fairview
- Overall star rating
- ★★★★☆ 4 of 5
- Health inspections
- ★★★★★ 5 of 5
- Staffing
- ★☆☆☆☆ 1 of 5
- Quality measures
- ★★★★☆ 4 of 5
- Type
- Medicare and Medicaid
- Ownership
- Non profit - Corporation
- Certified
- Dec 23, 2014
- Medicare certification status
- Active
- Certified beds
- 14 · 12.6 residents per day on average
- Chain
- Ebenezer Senior Living
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
Skilled nursing facility certification: CCN 245622
- Legal name
- EBENEZER LAKES ASSISTED LIVING
- Doing business as
- MEADOWS ON FAIRVIEW
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- Dec 23, 2014
- Last certification
- Apr 16, 2025
- Beds
- 14
- Ownership / control type
- Nonprofit Corporation
- Multi-facility organization
- Ebenezer Society
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jun 27, 2001 in MN
- Enrollment address
- 25565 Fairview Ave
Wyoming, MN 55092-8053 - Nursing home name
- MEADOWS ON FAIRVIEW
- Affiliated entity
- EBENEZER SENIOR LIVING
All disclosed owners & managing parties 17
| Name | Role | Since | Share |
|---|---|---|---|
| Susan Carlson-Weinberg |
Corporate Director | May 31, 2019 | |
| Yasser Chebli |
Operational/Managerial Control | Jan 1, 2022 | |
| Adp of the SNF | Apr 16, 2025 | ||
| Carolyn Jacobson |
Corporate Director | Oct 1, 2017 | |
| Brett Anderson |
Corporate Officer |
Sep 5, 2024 | |
| James Hereford |
Corporate Director | Aug 1, 2017 | |
| Todd Willett |
Corporate Officer |
Oct 24, 2016 | |
| Ebenezer Management Services Inc |
Operational/Managerial Control | Jan 1, 2018 | |
| Adp of the SNF | Jan 29, 2025 | ||
| Indirect Ownership Interest | Jan 1, 2018 | ||
| Scott Wordelman |
Corporate Director | Aug 24, 2017 | |
| Margaret Milius |
Corporate Director |
Feb 21, 2024 | |
| Robert Walker |
Corporate Director |
May 27, 2022 | |
| Mark Landreville |
Corporate Director |
Feb 21, 2024 | |
| Kenneth Piper |
Corporate Director |
May 27, 2022 | |
| Kayla Luraas |
Operational/Managerial Control | Jan 1, 2024 | |
| Adp of the SNF | Jul 22, 2025 | ||
| Kim Faust |
Corporate Director |
Jan 1, 2022 | |
| Ebenezer Society |
5% Or Greater Direct Ownership Interest | Jun 26, 2001 | 100% |
| Adp of the SNF | Nov 1, 2014 | ||
| Direct Ownership Interest | Nov 1, 2014 | 100% | |
| Gayle Kvenvold |
Corporate Director |
May 23, 2024 | |
| Brittany Bell |
Operational/Managerial Control | Sep 6, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20140702000102 | MN | Part a Provider - Skilled Nursing Facility | 1052551272 | Practice locations: Wyoming, MN |
National Provider Directory
- Tax ID family
- Ebenezer Lakes Assisted Living
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | Yes |
Addresses
Primary practice location
25565 Fairview Ave
Wyoming, MN 55092-8053
Mailing address
25565 Fairview Ave
Wyoming, MN 55092-8053
Phone (651) 982-6228
Other names
- Meadows on Fairview
Other providers in Wyoming, MN
- Julie Anne Desjardins
- Lauren Downie
- David C Drage
- Amy Beth Dronen
- Ebenezer Lakes Assisted Living
- Ebenezer Society, LLC
- Michael Donald Eichler
- John P Eikens
- Terrence Ellis
- Carlton R Erickson
All providers in Wyoming, MN · Skilled Nursing Facility in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 30, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.