Provider Demographics
NPI:1346235181
Name:MINNESOTA MASONIC HOME CARE CENTER
Entity Type:Organization
Organization Name:MINNESOTA MASONIC HOME CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOZK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-948-7000
Mailing Address - Street 1:11501 MASONIC HOME DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-3661
Mailing Address - Country:US
Mailing Address - Phone:952-948-7000
Mailing Address - Fax:
Practice Address - Street 1:11501 MASONIC HOME DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-3661
Practice Address - Country:US
Practice Address - Phone:952-948-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328757314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN511542600Medicaid
MN245343Medicare Oscar/Certification