Healthcare Provider Details

I. General information

NPI: 1689132490
Provider Name (Legal Business Name): FAIRHAVENS HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 87TH TRL N
BROOKLYN PARK MN
55443-3742
US

IV. Provider business mailing address

2608 87TH TRL N
BROOKLYN PARK MN
55443-3742
US

V. Phone/Fax

Practice location:
  • Phone: 763-222-4746
  • Fax: 763-888-0075
Mailing address:
  • Phone: 763-222-4746
  • Fax: 763-888-0075

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 Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. EMEKA LINUS CHIKWELU OKAFOR
Title or Position: PRESIDENT
Credential: RN
Phone: 763-222-4746