Provider Demographics
NPI: | 1922611011 |
---|---|
Name: | PROVIDENCE HOME CARE INC |
Entity Type: | Organization |
Organization Name: | PROVIDENCE HOME CARE INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | FAHIMA |
Authorized Official - Middle Name: | MOHAMED |
Authorized Official - Last Name: | ABDI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 612-978-2108 |
Mailing Address - Street 1: | 3423 26TH AVE S |
Mailing Address - Street 2: | |
Mailing Address - City: | MINNEAPOLIS |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55406-2505 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 612-978-2108 |
Mailing Address - Fax: | 612-486-9109 |
Practice Address - Street 1: | 3040 4TH AVE S STE 102 |
Practice Address - Street 2: | |
Practice Address - City: | MINNEAPOLIS |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55408-2409 |
Practice Address - Country: | US |
Practice Address - Phone: | 612-978-2108 |
Practice Address - Fax: | 612-486-9109 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-08-28 |
Last Update Date: | 2020-08-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251E00000X | Agencies | Home Health | |
No | 253Z00000X | Agencies | In Home Supportive Care | |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |