MEDICARE: CAMILIA ROSE GROUP HOME

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	1075259	MN

General Provider Information

NPI Number	:	1447390570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMILIA ROSE GROUP HOME

Provider Business Mailing Address
First Line	:	1555 118TH LN NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-7579
Country	:	US
Telephone Number	:	763-862-5436
Fax Number	:	763-754-0332

Provider Business Practice Location Address
First Line	:	1555 118TH LN NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-7579
Country	:	US
Telephone Number	:	763-862-5436
Fax Number	:	763-754-0332

Authorized Official
Title or Position	:	CONTROLLER
Name	:	CONNIE WINBAUER
Credential	:
Telephone Number	:	763-862-5436

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	08/22/2020

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