Provider Demographics
NPI:1275717936
Name:MINNESOTA COMMUNITY HOSPICE INC
Entity Type:Organization
Organization Name:MINNESOTA COMMUNITY HOSPICE INC
Other - Org Name:THE LODGE ON SUMMIT OAKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-319-1295
Mailing Address - Street 1:1412 SUMMIT OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4744
Mailing Address - Country:US
Mailing Address - Phone:952-431-9120
Mailing Address - Fax:952-431-9123
Practice Address - Street 1:1412 SUMMIT OAKS DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4744
Practice Address - Country:US
Practice Address - Phone:952-431-9120
Practice Address - Fax:952-431-9123
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA COMMUNITY HOSPICE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-18
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCLASS F HOME CARE PR310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN789488000Medicaid