MEDICARE: SUPPORTIVE HOUSING AND MANAGED CARE PILOT

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1417167917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE HOUSING AND MANAGED CARE PILOT

Provider Business Mailing Address
First Line	:	2801 21ST AVE S
Second Line	:	SUITE 130
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1226
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 21ST AVE S
Second Line	:	SUITE 130
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1226
Country	:	US
Telephone Number	:	612-724-0100
Fax Number	:

Authorized Official
Title or Position	:	SENIOR ACCOUNTANT AND ANALYST
Name	:	KAREN JOHNSEN
Credential	:
Telephone Number	:	612-724-0100

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/22/2020

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