Healthcare Provider Details

I. General information

NPI: 1366242117
Provider Name (Legal Business Name): KOASTAL HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 EAGLE POINT BLVD STE 100 SUITE 100
LAKE ELMO MN
55042-8648
US

IV. Provider business mailing address

8530 EAGLE POINT BLVD STE 100 SUITE 100
LAKE ELMO MN
55042-8648
US

V. Phone/Fax

Practice location:
  • Phone: 763-257-6780
  • Fax:
Mailing address:
  • Phone: 763-257-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: OTHER OTHER
Title or Position: MANAGER
Credential:
Phone: 763-257-6780