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NPI Code Detail

MEDICARE: MINNESOTA MASONIC HOME SENIOR OUTREACH SERVICES

MEDICARE: MINNESOTA MASONIC HOME SENIOR OUTREACH SERVICES
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
1261QA0600XAdult Day Care Clinic/Center802202MN

General Provider Information

NPI Number : 1396730131
Entity Type Code : Organization
Provider Name (Legal Business Name) : MINNESOTA MASONIC HOME SENIOR OUTREACH SERVICES
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 : 5430 BOONE AVE N
Second Line :
City : NEW HOPE
State : MN
Zip : 55428-3615
Country : US
Telephone Number : 763-592-3000
Fax Number :
Authorized Official
Title or Position : COO
Name : JON LUNDBERG
Credential :
Telephone Number : 952-948-7000
Provider Enumeration Date : 09/19/2005
Last Update Date : 08/22/2020

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Directions to “MINNESOTA MASONIC HOME SENIOR OUTREACH SERVICES ” Practice Location

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