Healthcare Provider Details

I. General information

NPI: 1508309451
Provider Name (Legal Business Name): OMOCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 COUNTY ROAD 10 STE 200A
BROOKLYN CENTER MN
55429-3065
US

IV. Provider business mailing address

7708 67TH AVE N
BROOKLYN PARK MN
55428-2212
US

V. Phone/Fax

Practice location:
  • Phone: 763-607-4300
  • Fax: 612-351-4259
Mailing address:
  • Phone: 762-607-4300
  • Fax: 612-351-4259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number379629
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number379629
License Number StateMN

VIII. Authorized Official

Name: RAPHAEL OMODUNMIJU
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 612-298-2513