Provider Demographics
NPI:1447390570
Name:CAMILIA ROSE GROUP HOME
Entity Type:Organization
Organization Name:CAMILIA ROSE GROUP HOME
Other - Org Name:MARY T ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WINBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-862-5436
Mailing Address - Street 1:1555 118TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-7579
Mailing Address - Country:US
Mailing Address - Phone:763-862-5436
Mailing Address - Fax:763-754-0332
Practice Address - Street 1:1555 118TH LN NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-7579
Practice Address - Country:US
Practice Address - Phone:763-862-5436
Practice Address - Fax:763-754-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1075259315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities