MEDICARE: MOUNT OLIVET ROLLING ACRES, INC

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

General Provider Information

NPI Number	:	1659720951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT OLIVET ROLLING ACRES, INC

Provider Business Mailing Address
First Line	:	9375 JAN VIEW LN
Second Line	:
City	:	WACONIA
State	:	MN
Zip	:	55387-9551
Country	:	US
Telephone Number	:	952-474-5974
Fax Number	:

Provider Business Practice Location Address
First Line	:	18986 LAKE DR E
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-9348
Country	:	US
Telephone Number	:	952-474-5974
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	BRUCE TORGERSON
Credential	:
Telephone Number	:	952-401-4847

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	06/14/2016

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