Healthcare Provider Details

I. General information

NPI: 1417721275
Provider Name (Legal Business Name): LAKESIDE HOME HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 11/13/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4124 QUEBEC AVE N STE 202
NEW HOPE MN
55427-1240
US

IV. Provider business mailing address

4124 QUEBEC AVE N STE 202
NEW HOPE MN
55427-1240
US

V. Phone/Fax

Practice location:
  • Phone: 651-363-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral 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: AHMED ABDULKADIR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-363-2020