Healthcare Provider Details

I. General information

NPI: 1669549887
Provider Name (Legal Business Name): PROVIDE CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4722 ISANTI TRL
NORTH BRANCH MN
55056-5420
US

IV. Provider business mailing address

PO BOX 538
NORTH BRANCH MN
55056-0538
US

V. Phone/Fax

Practice location:
  • Phone: 651-674-8312
  • Fax: 651-674-8299
Mailing address:
  • Phone: 651-674-8312
  • Fax: 651-674-8299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number045822800
License Number StateMN

VIII. Authorized Official

Name: SUSAN KAY ROD
Title or Position: COMPTROLLER
Credential:
Phone: 651-674-8312