MEDICARE: KAY GROUP HOME 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1629436738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAY GROUP HOME LLC

Provider Business Mailing Address
First Line	:	1520 CONCORDIA AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-5310
Country	:	US
Telephone Number	:	612-545-7533
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 CONCORDIA AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-5310
Country	:	US
Telephone Number	:	612-545-7533
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER/BILLER
Name	:	MUNA KHALIF SHEIKHABU
Credential	:
Telephone Number	:	612-545-7533

Provider Enumeration Date	:	02/03/2016
Last Update Date	:	02/03/2016

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