Healthcare Provider Details

I. General information

NPI: 1861108672
Provider Name (Legal Business Name): STATE OF MINNESOTA MINNESOTA MANAGEMENT AND BUDGET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 FIRST MINNESOTA
PRESTON MN
55965-2823
US

IV. Provider business mailing address

5101 MINNEHAHA AVE. S
MINNEAPOLIS MN
55417-1647
US

V. Phone/Fax

Practice location:
  • Phone: 507-765-7329
  • Fax: 612-548-5964
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SIMONE RENEE HOGAN
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 612-505-4110