=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073855813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | T&M ADULT FOSTER CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2013
-----------------------------------------------------
Last Update Date | 03/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 990 HAMMER AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55106-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-772-5374
-----------------------------------------------------
Fax | 651-772-5374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 990 HAMMER AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55106-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-772-5374
-----------------------------------------------------
Fax | 651-772-5374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROVIDER
-----------------------------------------------------
Name | MARY YANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-373-7135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 1064668-1-AFC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------