Healthcare Provider Details

I. General information

NPI: 1154675882
Provider Name (Legal Business Name): MOUNT OLIVET ROLLING ACRES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18986 LAKE DR E
CHANHASSEN MN
55317-9348
US

IV. Provider business mailing address

18986 LAKE DR E
CHANHASSEN MN
55317-9348
US

V. Phone/Fax

Practice location:
  • Phone: 952-474-5974
  • Fax: 952-767-1013
Mailing address:
  • Phone: 952-474-5974
  • Fax: 952-767-1013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number362143
License Number StateMN

VIII. Authorized Official

Name: KARI DOSE
Title or Position: OFFICE MANAGER
Credential:
Phone: 952-401-4843