Provider Demographics
NPI:1558529941
Name:SHOLOM COMMUNITY ALLIANCE HOME HEALTH CARE
Entity Type:Organization
Organization Name:SHOLOM COMMUNITY ALLIANCE HOME HEALTH CARE
Other - Org Name:SHOLOM HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WYCKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-939-1637
Mailing Address - Street 1:3630 PHILLIPS PKWY
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-3792
Mailing Address - Country:US
Mailing Address - Phone:952-939-1515
Mailing Address - Fax:952-933-1485
Practice Address - Street 1:3630 PHILLIPS PKWY
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3792
Practice Address - Country:US
Practice Address - Phone:952-939-1515
Practice Address - Fax:952-933-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN271243100Medicaid