MEDICARE: SHOLOM COMMUNITY ALLIANCE, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1972169159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOLOM COMMUNITY ALLIANCE, LLC

Provider Business Mailing Address
First Line	:	3610 PHILLIPS PKWY
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-3765
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3610 PHILLIPS PKWY
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-3765
Country	:	US
Telephone Number	:	952-908-1700
Fax Number	:

Authorized Official
Title or Position	:	CONTROLLER
Name	:	DOUGLAS WYCKOFF
Credential	:
Telephone Number	:	952-939-1637

Provider Enumeration Date	:	05/14/2019
Last Update Date	:	05/14/2019

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