MEDICARE: MSOCS-SWAN LAKE

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	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1558434399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MSOCS-SWAN LAKE

Provider Business Mailing Address
First Line	:	PO BOX 64979
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55164-0979
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1423 SWAN LAKE RD
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55811-4606
Country	:	US
Telephone Number	:	218-722-9449
Fax Number	:

Authorized Official
Title or Position	:	RESIDENTIAL PROG SVCS DIRECTOR
Name	:	ROGER DENEEN
Credential	:
Telephone Number	:	651-582-1857

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	08/22/2020

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Directions to “MSOCS-SWAN LAKE ” Practice Location

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