Provider Demographics
NPI:1134880461
Name:ANCHOR HOUSE LLC
Entity type:Organization
Organization Name:ANCHOR HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:OMOTOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDISON-EDEBOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-229-1012
Mailing Address - Street 1:5501 LAKELAND AVE N STE 101C
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3171
Mailing Address - Country:US
Mailing Address - Phone:763-843-1469
Mailing Address - Fax:
Practice Address - Street 1:6292 CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55429-1031
Practice Address - Country:US
Practice Address - Phone:763-432-5488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA574462400Medicaid
MNA427110300Medicaid
MNA487497100Medicaid