MEDICARE: WABE HOME 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1932975778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WABE HOME RESIDENTIAL SERVICES LLC

Provider Business Mailing Address
First Line	:	5177 RED OAK DR
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55112-4871
Country	:	US
Telephone Number	:	612-483-5750
Fax Number	:

Provider Business Practice Location Address
First Line	:	5177 RED OAK DR
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55112-4871
Country	:	US
Telephone Number	:	612-483-5750
Fax Number	:

Authorized Official
Title or Position	:	MANAGER /CO-OWNER
Name	:	MOHAMED IBRAHIM
Credential	:
Telephone Number	:	612-483-5750

Provider Enumeration Date	:	12/04/2023
Last Update Date	:	12/04/2023

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