MEDICARE: MOUNT OLIVET ROLLING ACRES

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	801603-3-RS	MN

General Provider Information

NPI Number	:	1801951934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT OLIVET ROLLING ACRES

Provider Business Mailing Address
First Line	:	18986 LAKE DR E
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-9348
Country	:	US
Telephone Number	:	952-401-4843
Fax Number	:	952-474-1148

Provider Business Practice Location Address
First Line	:	18986 LAKE DR E
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-9348
Country	:	US
Telephone Number	:	952-401-4843
Fax Number	:	952-474-1148

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KARI DOSE
Credential	:
Telephone Number	:	952-474-5974

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	04/09/2012

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