Healthcare Provider Details

I. General information

NPI: 1124771787
Provider Name (Legal Business Name): JLC HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 COUNTY ROAD B W STE 303
ROSEVILLE MN
55113-4104
US

IV. Provider business mailing address

1611 COUNTY ROAD B W STE 303
ROSEVILLE MN
55113-4104
US

V. Phone/Fax

Practice location:
  • Phone: 651-237-7727
  • Fax: 651-383-4145
Mailing address:
  • Phone: 651-237-7727
  • Fax: 651-383-4145

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: BRYAN CREMEEN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 651-983-2590