Healthcare Provider Details

I. General information

NPI: 1134880461
Provider Name (Legal Business Name): ANCHOR HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2022
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6292 CENTURY BLVD
BROOKLYN PARK MN
55429-1031
US

IV. Provider business mailing address

5501 LAKELAND AVE N STE 101C
CRYSTAL MN
55429-3171
US

V. Phone/Fax

Practice location:
  • Phone: 763-432-5488
  • Fax:
Mailing address:
  • Phone: 763-843-1469
  • 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 Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: OMOTOLA EDISON-EDEBOR
Title or Position: MANAGING MEMBER
Credential:
Phone: 612-229-1012