Healthcare Provider Details

I. General information

NPI: 1083172985
Provider Name (Legal Business Name): AGILITY ADVANTAGE HOME HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2019
Last Update Date: 03/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10339 QUAIL CIR N
BROOKLYN PARK MN
55443-5418
US

IV. Provider business mailing address

10339 QUAIL CIR N
BROOKLYN PARK MN
55443-5418
US

V. Phone/Fax

Practice location:
  • Phone: 612-212-9212
  • Fax:
Mailing address:
  • Phone: 612-212-9212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DIMITRA TUMBA KAULU
Title or Position: OWNER/MANAGER
Credential: LRT, CRT
Phone: 612-212-9212