MEDICARE: LUCKY HOME HEALTH CARE 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	:	1932654662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCKY HOME HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	2121 NICOLLET AVE STE 203
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2575
Country	:	US
Telephone Number	:	952-594-0532
Fax Number	:	651-683-2757

Provider Business Practice Location Address
First Line	:	2121 NICOLLET AVE STE 203
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2575
Country	:	US
Telephone Number	:	952-594-0532
Fax Number	:	651-683-2757

Authorized Official
Title or Position	:	OWNER
Name	:	OSAB OMAR ADEN
Credential	:	08/22/2016
Telephone Number	:	952-594-0532

Provider Enumeration Date	:	08/23/2016
Last Update Date	:	08/23/2016

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