Provider Demographics
NPI:1104026988
Name:KING DAVID HOME HEALTH CARE SERVICES LLC
Entity Type:Organization
Organization Name:KING DAVID HOME HEALTH CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:651-459-5023
Mailing Address - Street 1:7758 JANERO COURT SOUTH
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016
Mailing Address - Country:US
Mailing Address - Phone:651-459-5023
Mailing Address - Fax:651-769-0788
Practice Address - Street 1:7758 JANERO COURT SOUTH
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016
Practice Address - Country:US
Practice Address - Phone:651-459-5023
Practice Address - Fax:651-769-0788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN323248251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN323923000MedicaidMINNESOTA HEALTH CARE