Provider Demographics
NPI:1568243772
Name:GENTLE CARING MIND HEALTHCARE LLC
Entity Type:Organization
Organization Name:GENTLE CARING MIND HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TABUKUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-283-1185
Mailing Address - Street 1:3833 COON RAPIDS BLVD NW STE 260
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3833 COON RAPIDS BLVD NW STE 260
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2597
Practice Address - Country:US
Practice Address - Phone:651-283-1185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center