Healthcare Provider Details

I. General information

NPI: 1932035698
Provider Name (Legal Business Name): FULFILLEDLYF CARE AND COMMUNITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 COUNTY ROAD 10 STE 107
BROOKLYN CENTER MN
55429-3075
US

IV. Provider business mailing address

3220 COUNTY ROAD 10 STE 107
BROOKLYN CENTER MN
55429-3075
US

V. Phone/Fax

Practice location:
  • Phone: 612-346-3833
  • Fax: 415-484-7068
Mailing address:
  • Phone: 612-346-3833
  • Fax: 415-484-7068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: BRICE CONSTANTIN NGANADERE SERECKISSY
Title or Position: CEO
Credential:
Phone: 612-346-3833