Healthcare Provider Details

I. General information

NPI: 1457350720
Provider Name (Legal Business Name): MOUNT OLIVET DAY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LYNDALE AVE S
MINNEAPOLIS MN
55419-1721
US

IV. Provider business mailing address

5601 LYNDALE AVE S
MINNEAPOLIS MN
55419-1721
US

V. Phone/Fax

Practice location:
  • Phone: 612-827-5677
  • Fax: 612-821-3241
Mailing address:
  • Phone: 612-827-5677
  • Fax: 612-821-3241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number809494
License Number StateMN

VIII. Authorized Official

Name: MR. RICHARD A ANDERSON
Title or Position: CONTROLLER
Credential:
Phone: 612-821-3185