Healthcare Provider Details

I. General information

NPI: 1356989164
Provider Name (Legal Business Name): TAILORED CARE RESIDENCE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 10TH AVE S
MINNEAPOLIS MN
55404-3824
US

IV. Provider business mailing address

2311 10TH AVE S
MINNEAPOLIS MN
55404-3824
US

V. Phone/Fax

Practice location:
  • Phone: 651-352-5050
  • Fax:
Mailing address:
  • Phone: 651-352-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: ADAN DIRIE
Title or Position: PRESIDENT
Credential:
Phone: 651-352-5050