Healthcare Provider Details

I. General information

NPI: 1679280085
Provider Name (Legal Business Name): GAYLAH HOMECARE SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5410 37TH AVE S
FARGO ND
58104-7825
US

IV. Provider business mailing address

5410 37TH AVE S
FARGO ND
58104-7825
US

V. Phone/Fax

Practice location:
  • Phone: 701-946-2863
  • Fax:
Mailing address:
  • Phone: 701-946-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: GLADYS GAYLAH
Title or Position: OWNER
Credential:
Phone: 701-946-2863