Provider Demographics
NPI:1295087864
Name:ROSE OF SHARON
Entity type:Organization
Organization Name:ROSE OF SHARON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OCCUPATIONAL THERAPY ASSI
Authorized Official - Prefix:MS
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NINNEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:651-484-3378
Mailing Address - Street 1:1000 LOVELL AVE W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 LOVELL AVE W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4459
Practice Address - Country:US
Practice Address - Phone:651-484-3378
Practice Address - Fax:651-484-8982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201729314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1881768323Medicare NSC