=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346235181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINNESOTA MASONIC HOME CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2005
-----------------------------------------------------
Last Update Date | 12/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11501 MASONIC HOME DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55437-3661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-948-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11501 MASONIC HOME DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55437-3661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-948-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | SUE MOZK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-948-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 328757
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------