Provider Demographics
NPI:1396730131
Name:MINNESOTA MASONIC HOME SENIOR OUTREACH SERVICES
Entity type:Organization
Organization Name:MINNESOTA MASONIC HOME SENIOR OUTREACH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBERG
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 1:5430 BOONE AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3615
Practice Address - Country:US
Practice Address - Phone:763-592-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN802202261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care