MEDICARE: ESTATES AT ROSEVILLE LLC

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

General Provider Information

NPI Number	:	1861930331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESTATES AT ROSEVILLE LLC

Provider Business Mailing Address
First Line	:	638 SOUTHBEND AVE
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-2168
Country	:	US
Telephone Number	:	507-625-8741
Fax Number	:

Provider Business Practice Location Address
First Line	:	2727 VICTORIA ST N
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-3029
Country	:	US
Telephone Number	:	507-625-8741
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOSHUA LEGUM
Credential	:
Telephone Number	:	507-625-8741

Provider Enumeration Date	:	02/06/2017
Last Update Date	:	02/06/2017

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