=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265257877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OSWALD DEMA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2024
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 COUNTY ROAD 10 STE 200D
-----------------------------------------------------
City | BROOKLYN CENTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-886-4585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 COUNTY ROAD 10 STE 200D
-----------------------------------------------------
City | BROOKLYN CENTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-886-4585
-----------------------------------------------------
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 | 418044
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------