Provider Demographics
NPI:1629862560
Name:HEARTHSIDE CARE LLC
Entity type:Organization
Organization Name:HEARTHSIDE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AYUB
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-222-2222
Mailing Address - Street 1:12800 WHITEWATER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12800 WHITEWATER DR STE 100
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9347
Practice Address - Country:US
Practice Address - Phone:962-222-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service