=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124418330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLEGIANCE ABILITY ASSISTANCE HEALTH CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2015
-----------------------------------------------------
Last Update Date | 05/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1047 UNIVERSITY AVE W STE 102
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-4751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-747-8646
-----------------------------------------------------
Fax | 651-647-0909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1047 UNIVERSITY AVE W STE 102
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-4751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-747-8646
-----------------------------------------------------
Fax | 651-647-0909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ OWNER
-----------------------------------------------------
Name | KATHERINE WALETSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-747-8646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 366786
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------