Healthcare Provider Details

I. General information

NPI: 1295704005
Provider Name (Legal Business Name): SHOLOM COMMUNITY ALLIANCE HOME HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 PHILLIPS PARKWAY
ST LOUIS PARK MN
55426-3700
US

IV. Provider business mailing address

3620 PHILLIPS PARKWAY
ST LOUIS PARK MN
55426-3700
US

V. Phone/Fax

Practice location:
  • Phone: 952-935-6311
  • Fax: 952-935-2701
Mailing address:
  • Phone: 952-935-6311
  • Fax: 952-935-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DOUGLAS WYCKOFF
Title or Position: CONTROLLER
Credential:
Phone: 952-939-1637