Healthcare Provider Details

I. General information

NPI: 1396730131
Provider Name (Legal Business Name): MINNESOTA MASONIC HOME SENIOR OUTREACH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 BOONE AVE N
NEW HOPE MN
55428-3615
US

IV. Provider business mailing address

11501 MASONIC HOME DR
BLOOMINGTON MN
55437-3661
US

V. Phone/Fax

Practice location:
  • Phone: 763-592-3000
  • Fax:
Mailing address:
  • Phone: 952-948-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number802202
License Number StateMN

VIII. Authorized Official

Name: JON LUNDBERG
Title or Position: COO
Credential:
Phone: 952-948-7000