Healthcare Provider Details

I. General information

NPI: 1437957461
Provider Name (Legal Business Name): IDA'S HOUSE L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 IVY AVE E
SAINT PAUL MN
55106-2082
US

IV. Provider business mailing address

PO BOX 431403
BROOKLYN PARK MN
55443-7432
US

V. Phone/Fax

Practice location:
  • Phone: 612-327-0573
  • Fax:
Mailing address:
  • Phone: 612-327-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY DARNELL SCOTT
Title or Position: DIRECTOR/MANAGING AGENT
Credential:
Phone: 612-327-0573