MEDICARE: PRO-HEALTH HOME CARE AGENCY, 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	251E00000X	Home Health Agency	343901	MN

General Provider Information

NPI Number	:	1174847487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO-HEALTH HOME CARE AGENCY, LLC

Provider Business Mailing Address
First Line	:	4710 CENTRAL AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-1944
Country	:	US
Telephone Number	:	763-746-8155
Fax Number	:	763-746-8154

Provider Business Practice Location Address
First Line	:	4710 CENTRAL AVE NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-1944
Country	:	US
Telephone Number	:	763-746-8155
Fax Number	:	763-746-8154

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. ABDULWAHAB M ASAMARAI
Credential	:	M.D., PH.D.
Telephone Number	:	763-746-8155

Provider Enumeration Date	:	03/16/2010
Last Update Date	:	05/31/2016

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