Provider Demographics
NPI:1295286748
Name:CERTIFIED CARE INC
Entity type:Organization
Organization Name:CERTIFIED CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IYABO
Authorized Official - Middle Name:OLUWAKEMI
Authorized Official - Last Name:ADEYEMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-291-1162
Mailing Address - Street 1:4080 W BROADWAY AVE
Mailing Address - Street 2:#140A
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5604
Mailing Address - Country:US
Mailing Address - Phone:763-291-1162
Mailing Address - Fax:612-437-4934
Practice Address - Street 1:7340 NOBLE CT N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3465
Practice Address - Country:US
Practice Address - Phone:763-291-1162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1081849-1-HCBS253Z00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA236937000Medicaid