=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255125662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLOUS HOMECARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2025
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6130 ALBERT LN
-----------------------------------------------------
City | NORTH BRANCH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55056-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-290-3667
-----------------------------------------------------
Fax | 952-290-3667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6130 ALBERT LN
-----------------------------------------------------
City | NORTH BRANCH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55056-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-290-3667
-----------------------------------------------------
Fax | 952-290-3667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF OPERATIONS
-----------------------------------------------------
Name | LOGAN SHEPPARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-290-3667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------