Healthcare Provider Details

I. General information

NPI: 1467257873
Provider Name (Legal Business Name): FORTUNATE HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7006 E FISH LAKE RD
MAPLE GROVE MN
55311-2832
US

IV. Provider business mailing address

7006 E FISH LAKE RD
MAPLE GROVE MN
55311-2832
US

V. Phone/Fax

Practice location:
  • Phone: 952-994-5356
  • Fax: 952-674-7774
Mailing address:
  • Phone: 952-994-5356
  • Fax: 952-674-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: SUSAN OBWAYA
Title or Position: CEO/DESIGNATOR MANAGER
Credential:
Phone: 952-994-5356