Healthcare Provider Details

I. General information

NPI: 1194689059
Provider Name (Legal Business Name): HERITAGE GROVE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13555 TERRITORIAL CIR N
MAPLE GROVE MN
55369-4304
US

IV. Provider business mailing address

13555 TERRITORIAL CIR N
MAPLE GROVE MN
55369-4304
US

V. Phone/Fax

Practice location:
  • Phone: 571-789-5282
  • Fax:
Mailing address:
  • Phone: 202-365-2191
  • 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: FAHIMA ABDULKADIR
Title or Position: OWNER
Credential:
Phone: 202-365-2191