Healthcare Provider Details

I. General information

NPI: 1366047813
Provider Name (Legal Business Name): ACTIVCARE SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7047 GOODVIEW AVE S
COTTAGE GROVE MN
55016-2696
US

IV. Provider business mailing address

7047 GOODVIEW AVE S
COTTAGE GROVE MN
55016-2696
US

V. Phone/Fax

Practice location:
  • Phone: 651-983-3703
  • Fax:
Mailing address:
  • Phone: 651-983-3703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: THANDIWE DEWA
Title or Position: PRESIDENT
Credential:
Phone: 651-983-3703