Healthcare Provider Details

I. General information

NPI: 1376349142
Provider Name (Legal Business Name): PRIMER SUPPORTIVE NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7597 UPPER 24TH ST N
OAKDALE MN
55128-5025
US

IV. Provider business mailing address

7597 UPPER 24TH ST N
OAKDALE MN
55128-5025
US

V. Phone/Fax

Practice location:
  • Phone: 651-278-9352
  • Fax:
Mailing address:
  • Phone: 651-278-9352
  • 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 Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY NGOCHO NASILAI
Title or Position: CEO
Credential:
Phone: 651-278-9352