Healthcare Provider Details

I. General information

NPI: 1205699113
Provider Name (Legal Business Name): FAMILY ALLIANCE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 CEDAR LAKE RD S UNIT H-106
ST LOUIS PARK MN
55416-1487
US

IV. Provider business mailing address

5821 CEDAR LAKE RD S UNIT H-106
ST LOUIS PARK MN
55416-1487
US

V. Phone/Fax

Practice location:
  • Phone: 763-221-4774
  • Fax: 763-269-7481
Mailing address:
  • Phone: 763-221-4774
  • Fax: 763-269-7481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GOODIE OSHIAPI ILUEBBEY
Title or Position: RN
Credential: REGISTERED NURSE
Phone: 763-221-4774