Provider Demographics
NPI:1639567977
Name:WALLINGBURG HOME CARE SERVICES
Entity Type:Organization
Organization Name:WALLINGBURG HOME CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDISHAKUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-978-1821
Mailing Address - Street 1:2630 UNIVERSITY AVE SE STE A158
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3264
Mailing Address - Country:US
Mailing Address - Phone:612-978-1821
Mailing Address - Fax:612-354-2310
Practice Address - Street 1:2630 UNIVERSITY AVE SE STE A158
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3264
Practice Address - Country:US
Practice Address - Phone:612-978-1821
Practice Address - Fax:612-354-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26340582251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA504140000Medicaid