NPIMap

Organization Active NPI

Ebenezer Lakes Assisted Living

Doing business as Meadows on Fairview

  • Skilled Nursing Facility
  • Wyoming, MN
National Provider Identifier
1679916571
Registry record updated Dec 30, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
EBENEZER LAKES ASSISTED LIVING
Doing business as
Meadows on Fairview
Practice address
25565 Fairview Ave
Wyoming, MN 55092-8053
Phone
(651) 982-6228
Fax
(651) 466-0714
NPI assigned
Apr 10, 2013
Last updated
Dec 30, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 30, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Kari Beth Wilson, LNHA
Title
Campus Director
Phone
(651) 982-6228

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

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 1

  • Meadows on Fairview Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140702000102 MN Part A Provider - Skilled Nursing Facility 1052551272 Practice locations: Wyoming, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679916571. Details of each certification follow.

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
CorporationNon-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

Care Compare: Nursing home

Medicare Care Compare
Listed as
Meadows on FairviewCCN 245622 · All quality measures
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
ActiveFrom the Provider of Services file
Certified beds
1412.6 residents per day on average
Chain
Ebenezer Senior Living6 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Ebenezer Lakes Assisted Living2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Susan Carlson-Weinberg Individual Corporate Director May 31, 2019
Yasser Chebli Individual Operational/Managerial Control Jan 1, 2022
Adp of the SNF Apr 16, 2025
Carolyn Jacobson Individual Corporate Director Oct 1, 2017
Brett Anderson Individual Corporate OfficerPresident/Ceo Sep 5, 2024
James Hereford Individual Corporate Director Aug 1, 2017
Todd Willett Individual Corporate OfficerChief Financial Officer Oct 24, 2016
Ebenezer Management Services Inc Organization, Edina, MN Corporation, For-profit Operational/Managerial Control Jan 1, 2018
Adp of the SNF Jan 29, 2025
Indirect Ownership Interest Jan 1, 2018
Scott Wordelman Individual Corporate Director Aug 24, 2017
Margaret Milius Individual Corporate DirectorBoard Member Feb 21, 2024
Robert Walker Individual Corporate DirectorBoard Member May 27, 2022
Mark Landreville Individual Corporate DirectorBoard Member Feb 21, 2024
Kenneth Piper Individual Corporate DirectorBoard Member May 27, 2022
Kayla Luraas Individual Operational/Managerial Control Jan 1, 2024
Adp of the SNF Jul 22, 2025
Kim Faust Individual Corporate DirectorBoard Member Jan 1, 2022
Ebenezer Society Organization, Edina, MN Non-profit, Chain home office 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 Individual Corporate DirectorBoard Member May 23, 2024
Brittany Bell Individual Operational/Managerial Control Sep 6, 2021

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Yasser Chebli, MD
    • Geriatric Medicine (Family Medicine) Physician
    • Saint Paul, MN
    • NPI 1366704553

    Adp of the SNF, Operational/Managerial Control

    CMS ownership
  • Ebenezer Management Services Inc
    • Long Term Care Pharmacy
    • Arden Hills, MN
    • NPI 1962355073

    Adp of the SNF, Indirect Ownership Interest, Operational/Managerial Control

    CMS ownership
  • Ebenezer Society

    dba Ebenezer Care Center

    • Skilled Nursing Facility
    • Minneapolis, MN
    • NPI 1184622870

    5% Or Greater Direct Ownership Interest, Adp of the SNF, Direct Ownership Interest

    CMS ownership

Facilities with the same owner 7

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1365552000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1483056000000",
    "number": "1679916571",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25565 FAIRVIEW AVE",
            "city": "WYOMING",
            "state": "MN",
            "postal_code": "550928053",
            "telephone_number": "651-982-6228",
            "fax_number": "651-466-0714"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25565 FAIRVIEW AVE",
            "city": "WYOMING",
            "state": "MN",
            "postal_code": "550928053",
            "telephone_number": "651-982-6228",
            "fax_number": "651-466-0714"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EBENEZER LAKES ASSISTED LIVING",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-04-10",
        "last_updated": "2016-12-30",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "KARI",
        "authorized_official_middle_name": "BETH",
        "authorized_official_title_or_position": "CAMPUS DIRECTOR",
        "authorized_official_telephone_number": "651-982-6228",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "LNHA"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Meadows on Fairview",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wyoming, MN

Sources for this page

Verify at the official NPI Registry.