Provider Demographics
NPI:1679278949
Name:ELICIA HOMECARE SERVICES LLC
Entity Type:Organization
Organization Name:ELICIA HOMECARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELLE
Authorized Official - Middle Name:CLERMONT
Authorized Official - Last Name:KANNEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-709-3880
Mailing Address - Street 1:12153 72ND ST NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-5064
Mailing Address - Country:US
Mailing Address - Phone:612-709-3880
Mailing Address - Fax:612-454-2583
Practice Address - Street 1:12153 72ND ST NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-5064
Practice Address - Country:US
Practice Address - Phone:612-709-3880
Practice Address - Fax:612-454-2583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness