Healthcare Provider Details

I. General information

NPI: 1629862560
Provider Name (Legal Business Name): HEARTHSIDE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

IV. Provider business mailing address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

V. Phone/Fax

Practice location:
  • Phone: 962-222-2222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AYUB MOHAMED
Title or Position: CEO
Credential:
Phone: 952-222-2222