=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255736930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOJOURN ADULT DAY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2014
-----------------------------------------------------
Last Update Date | 10/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5200 MAYWOOD RD
-----------------------------------------------------
City | MOUND
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55364-1775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-471-6080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 MAYWOOD RD
-----------------------------------------------------
City | MOUND
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55364-1775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-471-6080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | MR. THOMAS HANCE PENN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-590-9250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 802258-5-ADC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------