MEDICARE: CUSTOMCARE CBC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	385H00000X	Respite Care
3	311Z00000X	Custodial Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	416174	OTHER	MN	MDH- TEMPORARY COMPREHENSIVE HOME CARE LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922185677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOMCARE CBC, LLC

Provider Business Mailing Address
First Line	:	7801 E BUSH LAKE RD STE 100
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55439-3111
Country	:	US
Telephone Number	:	952-914-0269
Fax Number	:	952-960-0239

Provider Business Practice Location Address
First Line	:	7801 E BUSH LAKE RD STE 100
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55439-3111
Country	:	US
Telephone Number	:	952-914-0269
Fax Number	:	952-960-0239

Authorized Official
Title or Position	:	CFO
Name	:	KENNETH DUARTE
Credential	:
Telephone Number	:	336-553-5912

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	10/14/2025

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