Provider Demographics
NPI:1457587321
Name:1 GALAXY OF DIVINE CARING, INC.
Entity Type:Organization
Organization Name:1 GALAXY OF DIVINE CARING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ODS
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:O
Authorized Official - Last Name:BASSEY-BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-463-9313
Mailing Address - Street 1:13570 GROVE DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4400
Mailing Address - Country:US
Mailing Address - Phone:763-463-9313
Mailing Address - Fax:763-494-6709
Practice Address - Street 1:13570 GROVE DR
Practice Address - Street 2:SUITE 211
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4400
Practice Address - Country:US
Practice Address - Phone:763-463-9313
Practice Address - Fax:763-494-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN343527251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA867672200Medicaid