Provider Demographics
NPI:1144610403
Name:REST EASY AT HOME HEALTH CARE AGENCY, LLC
Entity Type:Organization
Organization Name:REST EASY AT HOME HEALTH CARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:FULTON
Authorized Official - Last Name:HOCKENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-342-2478
Mailing Address - Street 1:1825 CURVE CREST BLVD W
Mailing Address - Street 2:200
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5090
Mailing Address - Country:US
Mailing Address - Phone:651-342-2478
Mailing Address - Fax:651-342-0282
Practice Address - Street 1:1825 CURVE CREST BLVD W
Practice Address - Street 2:200
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5090
Practice Address - Country:US
Practice Address - Phone:651-342-2478
Practice Address - Fax:651-342-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30914251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1548674039Medicaid