Healthcare Provider Details

I. General information

NPI: 1407636145
Provider Name (Legal Business Name): DISTINCTIVE HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7473 160TH AVE NW
RAMSEY MN
55303-6623
US

IV. Provider business mailing address

7473 160TH AVE NW
RAMSEY MN
55303-6623
US

V. Phone/Fax

Practice location:
  • Phone: 612-709-3880
  • Fax:
Mailing address:
  • Phone: 612-709-3880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANGELLE CLERMONT KANNEH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-709-3880