Provider Demographics
NPI:1225796097
Name:MIKAYE, VINCENT
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:MIKAYE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8119 UPTON AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1235
Mailing Address - Country:US
Mailing Address - Phone:612-203-7090
Mailing Address - Fax:
Practice Address - Street 1:8119 UPTON AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1235
Practice Address - Country:US
Practice Address - Phone:612-203-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility