Provider Demographics
NPI:1952978728
Name:MARY R. SENIOR CARE & HOME CARE SERVICES AGENCY LLC
Entity Type:Organization
Organization Name:MARY R. SENIOR CARE & HOME CARE SERVICES AGENCY LLC
Other - Org Name:MARY R. SENIOR CARE & HOME CARE SERVICES AGENCY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DININA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:952-688-9499
Mailing Address - Street 1:1615 S 4TH ST APT M3306
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1364
Mailing Address - Country:US
Mailing Address - Phone:952-688-9499
Mailing Address - Fax:
Practice Address - Street 1:1615 S 4TH ST APT M3306
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1364
Practice Address - Country:US
Practice Address - Phone:952-688-9499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-09
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1720654056Medicaid