=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194906495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K & B HEALTH CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1428 109TH AVE NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-862-0169
-----------------------------------------------------
Fax | 763-862-0365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1428 109TH AVE NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-862-0169
-----------------------------------------------------
Fax | 763-862-0365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM ADMINISTRATOR
-----------------------------------------------------
Name | KOLADE COKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-862-0169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 335537
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------