MEDICARE: NOVA CARE CENTER LLC

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1174240204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA CARE CENTER LLC

Provider Business Mailing Address
First Line	:	8673 COLUMBINE RD
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-7668
Country	:	US
Telephone Number	:	612-964-0142
Fax Number	:

Provider Business Practice Location Address
First Line	:	8673 COLUMBINE RD
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-7668
Country	:	US
Telephone Number	:	612-964-0142
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	AYAN ABDI MAHAMUD
Credential	:
Telephone Number	:	612-964-0142

Provider Enumeration Date	:	10/19/2022
Last Update Date	:	04/29/2023

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