MEDICARE: OUR HOUSE OF MINNESOTA, 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	315P00000X	Intellectual Disabilities Intermediate Care Facility	801827-1-RS	MN

General Provider Information

NPI Number	:	1568563898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR HOUSE OF MINNESOTA, INC.

Provider Business Mailing Address
First Line	:	1846 PORTLAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6062
Country	:	US
Telephone Number	:	651-646-1104
Fax Number	:	651-646-1104

Provider Business Practice Location Address
First Line	:	1846 PORTLAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6062
Country	:	US
Telephone Number	:	651-646-1104
Fax Number	:	651-646-1104

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DENNIS HOLMAN
Credential	:
Telephone Number	:	651-646-1104

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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