=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093355216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BURHAN ADAM DAYNAB ASSISTED LIVING
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2020
-----------------------------------------------------
Last Update Date | 03/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1609 EDGEWOOD AVE S
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55426-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-564-0682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1609 EDGEWOOD AVE S
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55426-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-564-0682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------