Healthcare Provider Details

I. General information

NPI: 1659120830
Provider Name (Legal Business Name): HOMEBASE SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2024
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14889 NOKAY LAKE RD
BRAINERD MN
56401-5595
US

IV. Provider business mailing address

14889 NOKAY LAKE RD
BRAINERD MN
56401-5595
US

V. Phone/Fax

Practice location:
  • Phone: 218-831-8710
  • Fax:
Mailing address:
  • Phone: 218-831-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: RYAN CHRISTOPHER MENZEL
Title or Position: PRESIDENT
Credential:
Phone: 218-831-8710