MEDICARE: ALDRICH BOARDING CARE HOME, LLC

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	800642-2-RS	MN
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	535543500	OTHER	MN	STATE PROVIDER NUMBER

General Provider Information

NPI Number	:	1336200922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALDRICH BOARDING CARE HOME, LLC

Provider Business Mailing Address
First Line	:	1932 UNIVERSITY AVENUE WEST
Second Line	:
City	:	ST. PAUL
State	:	MN
Zip	:	55104
Country	:	US
Telephone Number	:	612-695-6041
Fax Number	:	651-528-8427

Provider Business Practice Location Address
First Line	:	1932 UNIVERSITY AVENUE WEST
Second Line	:
City	:	ST. PAUL
State	:	MN
Zip	:	55104
Country	:	US
Telephone Number	:	612-695-6041
Fax Number	:	651-528-8427

Authorized Official
Title or Position	:	CHIEF OPERATIONS OFFICER
Name	:	PAUL GANS
Credential	:
Telephone Number	:	952-913-5990

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	10/02/2019

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