MEDICARE: AXIS MINNESOTA, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	1028070-1-RS	MN

General Provider Information

NPI Number	:	1265596886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIS MINNESOTA, INC.

Provider Business Mailing Address
First Line	:	2345 RICE ST STE 112
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-3745
Country	:	US
Telephone Number	:	651-774-5940
Fax Number	:	651-774-8126

Provider Business Practice Location Address
First Line	:	3516 WHITE BEAR AVE N
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-5419
Country	:	US
Telephone Number	:	651-774-5940
Fax Number	:	651-774-8126

Authorized Official
Title or Position	:	CFO
Name	:	DENIES MARIE SCHOLLJEGERDES
Credential	:
Telephone Number	:	651-774-5940

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	08/22/2020

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