Provider Demographics
NPI:1275841181
Name:AVALON HOME CARE
Entity Type:Organization
Organization Name:AVALON HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:JUDISCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-753-8658
Mailing Address - Street 1:20132 ULYSSES ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20132 ULYSSES ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2254
Practice Address - Country:US
Practice Address - Phone:763-753-8658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA003607200OtherMEDICARE
MNA003607200Medicaid