MEDICARE: MINNESOTA MASONIC HOME CARE CENTER

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	314000000X	Skilled Nursing Facility	328757	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346235181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA MASONIC HOME CARE CENTER

Provider Business Mailing Address
First Line	:	11501 MASONIC HOME DR
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55437-3661
Country	:	US
Telephone Number	:	952-948-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	11501 MASONIC HOME DR
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55437-3661
Country	:	US
Telephone Number	:	952-948-7000
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	SUE MOZK
Credential	:
Telephone Number	:	952-948-7000

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	12/15/2015

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