MEDICARE: PRESTIGE HEALTH CARE SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	337387	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	337386	OTHER	MN	CLASS F
2	337387	OTHER	MN	CLASS A

General Provider Information

NPI Number	:	1033302971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE HEALTH CARE SERVICES

Provider Business Mailing Address
First Line	:	10937 ROBINSON DR NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-4248
Country	:	US
Telephone Number	:	763-607-5184
Fax Number	:	763-226-2378

Provider Business Practice Location Address
First Line	:	10937 ROBINSON DR NW
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-4248
Country	:	US
Telephone Number	:	763-607-5184
Fax Number	:	763-226-2378

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MISS TABITHA R KYAMBADDE
Credential	:
Telephone Number	:	763-607-5184

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	08/23/2007

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