Provider Demographics
NPI:1649779828
Name:TRISTAR HOME CARE LLC
Entity Type:Organization
Organization Name:TRISTAR HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OZURUMBA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:651-336-6815
Mailing Address - Street 1:9402 93RD ST S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4096
Mailing Address - Country:US
Mailing Address - Phone:763-415-5471
Mailing Address - Fax:763-204-8141
Practice Address - Street 1:3000 80TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-1836
Practice Address - Country:US
Practice Address - Phone:763-415-5471
Practice Address - Fax:763-292-9041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN385032251E00000X
251E00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN385032OtherCOMPREHENSIVE HOME CARE LICENSE
MN1649779828OtherCOMPREHENSIVE HOME CARE LICENSE