Provider Demographics
NPI:1003172594
Name:MOUNT OLIVET ROLLING ACRES, INC
Entity Type:Organization
Organization Name:MOUNT OLIVET ROLLING ACRES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:DOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-401-4843
Mailing Address - Street 1:18986 LAKE DR E
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9348
Mailing Address - Country:US
Mailing Address - Phone:952-474-5974
Mailing Address - Fax:952-474-3652
Practice Address - Street 1:1603 W OLD SHAKOPEE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3065
Practice Address - Country:US
Practice Address - Phone:952-401-4868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC09399Medicare Oscar/Certification