MEDICARE: SOJOURN ADULT DAY SERVICES 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	261QA0600X	Adult Day Care Clinic/Center	802258-5-ADC	MN

General Provider Information

NPI Number	:	1255736930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOJOURN ADULT DAY SERVICES LLC

Provider Business Mailing Address
First Line	:	5200 MAYWOOD RD
Second Line	:
City	:	MOUND
State	:	MN
Zip	:	55364-1775
Country	:	US
Telephone Number	:	952-471-6080
Fax Number	:

Provider Business Practice Location Address
First Line	:	5200 MAYWOOD RD
Second Line	:
City	:	MOUND
State	:	MN
Zip	:	55364-1775
Country	:	US
Telephone Number	:	952-471-6080
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	MR. THOMAS HANCE PENN
Credential	:
Telephone Number	:	612-590-9250

Provider Enumeration Date	:	10/24/2014
Last Update Date	:	10/24/2014

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