MEDICARE: ST. OLAF RESIDENCE, INC.

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	314000000X	Skilled Nursing Facility	00260	MN

General Provider Information

NPI Number	:	1255337796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. OLAF RESIDENCE, INC.

Provider Business Mailing Address
First Line	:	2912 FREMONT AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1313
Country	:	US
Telephone Number	:	612-522-6561
Fax Number	:	612-522-2921

Provider Business Practice Location Address
First Line	:	2912 FREMONT AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1313
Country	:	US
Telephone Number	:	612-522-6561
Fax Number	:	612-522-2921

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. TIMOTHY MEYER
Credential	:
Telephone Number	:	612-287-3538

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	08/22/2020

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