Healthcare Provider Details

I. General information

NPI: 1417749409
Provider Name (Legal Business Name): GRACE HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SILVER LAKE RD NW STE 22
NEW BRIGHTON MN
55112-9301
US

IV. Provider business mailing address

1405 SILVER LAKE RD NW STE 22
NEW BRIGHTON MN
55112-9301
US

V. Phone/Fax

Practice location:
  • Phone: 612-851-6577
  • Fax:
Mailing address:
  • Phone: 612-851-6577
  • 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

VIII. Authorized Official

Name: MOHAMUD MOHAMUD
Title or Position: OWNER
Credential:
Phone: 612-327-2549