MEDICARE: ANGELS OF INDEPENDENCE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	163W00000X	Registered Nurse
2	376J00000X	Homemaker
3	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1477783082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELS OF INDEPENDENCE

Provider Business Mailing Address
First Line	:	26992 LAKE JEFFERSON RD.
Second Line	:
City	:	CLEVELAND
State	:	MN
Zip	:	56017-4448
Country	:	US
Telephone Number	:	507-550-4108
Fax Number	:	507-550-4108

Provider Business Practice Location Address
First Line	:	26992 LAKE JEFFERSON ROAD
Second Line	:
City	:	CLEVELAND
State	:	MN
Zip	:	56017-4440
Country	:	US
Telephone Number	:	507-213-1486
Fax Number	:	507-550-4108

Authorized Official
Title or Position	:	PRESIDENT C.E.O.
Name	:	MRS. MARY KAY GOETTI
Credential	:	CNA, HHA
Telephone Number	:	507-213-1486

Provider Enumeration Date	:	07/16/2009
Last Update Date	:	07/16/2009

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Directions to “ANGELS OF INDEPENDENCE ” Practice Location

Language	Start Address	Practice Location

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