Healthcare Provider Details

I. General information

NPI: 1508566555
Provider Name (Legal Business Name): SECURED HEALTH AND HOME ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10410 CROCUS ST NW
COON RAPIDS MN
55433-4513
US

IV. Provider business mailing address

4519 104TH AVE N
BROOKLYN PARK MN
55443-1030
US

V. Phone/Fax

Practice location:
  • Phone: 763-438-8869
  • Fax: 763-207-1086
Mailing address:
  • Phone: 763-438-8869
  • Fax: 763-207-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: ABIOLA IJADIMBOLA
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: ALD
Phone: 763-438-8869