Healthcare Provider Details

I. General information

NPI: 1457162059
Provider Name (Legal Business Name): BLAINE HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13250 NASSAU CT NE
BLAINE MN
55449-4989
US

IV. Provider business mailing address

13250 NASSAU CT NE
BLAINE MN
55449-4989
US

V. Phone/Fax

Practice location:
  • Phone: 763-318-5008
  • Fax:
Mailing address:
  • Phone: 763-318-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: VALENTINE B OBWOGI
Title or Position: OWNER/CEO
Credential:
Phone: 763-318-5008