Healthcare Provider Details

I. General information

NPI: 1134857543
Provider Name (Legal Business Name): AGAPE ASSISTED LIVING & HOUSING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 BUCHANAN ST NE UNIT B
MINNEAPOLIS MN
55413-2501
US

IV. Provider business mailing address

8781 GRANITE LN
WOODBURY MN
55129-2226
US

V. Phone/Fax

Practice location:
  • Phone: 651-890-7649
  • Fax: 612-460-6454
Mailing address:
  • Phone: 651-890-7649
  • Fax: 612-460-6454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LACHANDRA CHANTE GUMS
Title or Position: OWNER/ALD
Credential: RN
Phone: 651-890-7649