- Enrollment id
- O20180212002942
- Enrollment state
- MN
- Provider type code
- 00-08
- Provider type text
- PART A PROVIDER - HOSPICE
- Npi
- 1871024794
- Multiple npi flag
- N
- Ccn
- 241603
- Associate id
- 7315207370
- Organization name
- OLIVE GROVE HOSPICE LLC
- Incorporation date
- 2017-03-06
- Incorporation state
- MN
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Address line 1
- 12402 JAMESTOWN ST NE
- Address line 2
- STE 200
- City
- BLAINE
- State
- MN
- Zip code
- 554497541