Healthcare Provider Details

I. General information

NPI: 1679219653
Provider Name (Legal Business Name): GABBY CARE HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 PENNSYLVANIA AVE N
CHAMPLIN MN
55316-2017
US

IV. Provider business mailing address

18594 TYLER ST NW
ELK RIVER MN
55330-4509
US

V. Phone/Fax

Practice location:
  • Phone: 952-649-1097
  • Fax:
Mailing address:
  • Phone: 952-649-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL OBWAYA
Title or Position: OWNER/RN/ASSIT. ADMIN
Credential: RN
Phone: 952-649-1097