MEDICARE: MOUNT OLIVET DAY 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
1	261QA0600X	Adult Day Care Clinic/Center	809494	MN

General Provider Information

NPI Number	:	1457350720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT OLIVET DAY SERVICES

Provider Business Mailing Address
First Line	:	5601 LYNDALE AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1721
Country	:	US
Telephone Number	:	612-827-5677
Fax Number	:	612-821-3241

Provider Business Practice Location Address
First Line	:	5601 LYNDALE AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1721
Country	:	US
Telephone Number	:	612-827-5677
Fax Number	:	612-821-3241

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MR. RICHARD A ANDERSON
Credential	:
Telephone Number	:	612-821-3185

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	08/22/2020

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