Healthcare Provider Details

I. General information

NPI: 1255125662
Provider Name (Legal Business Name): MARYLOUS HOMECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6130 ALBERT LN
NORTH BRANCH MN
55056-3303
US

IV. Provider business mailing address

6130 ALBERT LN
NORTH BRANCH MN
55056-3303
US

V. Phone/Fax

Practice location:
  • Phone: 952-290-3667
  • Fax: 952-290-3667
Mailing address:
  • Phone: 952-290-3667
  • Fax: 952-290-3667

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: LOGAN SHEPPARD
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 952-290-3667