MEDICARE: DOMINION HEALTHCARE SERVICES 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

General Provider Information

NPI Number	:	1639710460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION HEALTHCARE SERVICES LLC

Provider Business Mailing Address
First Line	:	6918 GRIMES AVE N
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-1450
Country	:	US
Telephone Number	:	612-258-8794
Fax Number	:

Provider Business Practice Location Address
First Line	:	6918 GRIMES AVE N
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-1450
Country	:	US
Telephone Number	:	612-258-8794
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	YARIA ISABELLA BANGURA
Credential	:
Telephone Number	:	612-812-4744

Provider Enumeration Date	:	10/02/2019
Last Update Date	:	06/24/2022

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Directions to “DOMINION HEALTHCARE SERVICES LLC ” Practice Location

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