Healthcare Provider Details

I. General information

NPI: 1124838123
Provider Name (Legal Business Name): SHEBA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2025
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 DAHL AVE E
MAPLEWOOD MN
55119-5831
US

IV. Provider business mailing address

2303 DAHL AVE E
MAPLEWOOD MN
55119-5831
US

V. Phone/Fax

Practice location:
  • Phone: 651-354-8821
  • Fax:
Mailing address:
  • Phone: 651-354-8821
  • Fax:

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 Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: SIMELE ADIMASU
Title or Position: MANAGER
Credential:
Phone: 651-354-8821