MEDICARE: KIMBERLY HOMES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1023254331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIMBERLY HOMES LLC

Provider Business Mailing Address
First Line	:	8041 SCOTT AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55443-2353
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8041 SCOTT AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55443-2353
Country	:	US
Telephone Number	:	763-742-8271
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	KIMBERLY RAY
Credential	:
Telephone Number	:	763-742-8271

Provider Enumeration Date	:	12/17/2008
Last Update Date	:	12/17/2008

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