Healthcare Provider Details

I. General information

NPI: 1790593531
Provider Name (Legal Business Name): MAMA HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 6TH AVENUE N STE B
FARGO ND
58102
US

IV. Provider business mailing address

510 6TH AVENUE N STE B
FARGO ND
58102
US

V. Phone/Fax

Practice location:
  • Phone: 480-886-7148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BONIFACE MAKUNYI
Title or Position: GENERAL MANAGER
Credential:
Phone: 480-886-7148