Healthcare Provider Details

I. General information

NPI: 1063329985
Provider Name (Legal Business Name): EL-SHADDAI ASSISTED LIVING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2566 112TH AVE NW
COON RAPIDS MN
55433-3562
US

IV. Provider business mailing address

2566 112TH AVE NW
COON RAPIDS MN
55433-3562
US

V. Phone/Fax

Practice location:
  • Phone: 612-735-3136
  • Fax:
Mailing address:
  • Phone: 612-735-3136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: CHALTU RABU
Title or Position: OWNER/MANAGER
Credential:
Phone: 612-735-3136