Healthcare Provider Details

I. General information

NPI: 1922628874
Provider Name (Legal Business Name): REDESIGN LIFESTYLE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 MORGAN AVE N
MINNEAPOLIS MN
55411-3013
US

IV. Provider business mailing address

4725 MINNETONKA BLVD APT 301
SAINT LOUIS PARK MN
55416-2240
US

V. Phone/Fax

Practice location:
  • Phone: 612-963-2576
  • Fax: 612-238-8055
Mailing address:
  • Phone: 612-963-2576
  • Fax: 612-238-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: HAMDI ALI MOHAMED
Title or Position: OWNER
Credential:
Phone: 612-963-2576