=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275123200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN LAKES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2021
-----------------------------------------------------
Last Update Date | 10/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 277 COON RAPIDS BLVD NW STE 414
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-888-5040
-----------------------------------------------------
Fax | 612-688-7440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 277 COON RAPIDS BLVD NW STE 414
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-888-5040
-----------------------------------------------------
Fax | 612-688-7440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | FOLARIN ADEDEJI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-888-5040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------