MEDICARE: NORTH STAR RESIDENTIAL 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	104100000X	Social Worker
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1801530233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH STAR RESIDENTIAL SERVICES LLC

Provider Business Mailing Address
First Line	:	5701 SHINGLE CREEK PKWY STE 210F
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55430-2330
Country	:	US
Telephone Number	:	612-978-1992
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 SHINGLE CREEK PKWY STE 210F
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55430-2330
Country	:	US
Telephone Number	:	612-978-1992
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. AHMED ABDULKADIR
Credential	:
Telephone Number	:	612-978-1992

Provider Enumeration Date	:	04/22/2022
Last Update Date	:	09/21/2022

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