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General NPI Number Information
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NPI Number | 1285410746
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Entity Type | Organization
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Legal Business Name | PROVENANCE HOMES
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Dates
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Enumeration Date | 08/31/2023
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 1650 W END BLVD STE 100
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-5369
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Country | US
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Telephone | 612-261-6988
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Fax | 612-465-1402
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Provider Business Mailing Address
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Address Line | 1650 W END BLVD STE 100
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-5369
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Country | US
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Telephone | 612-261-6988
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Fax | 612-465-1402
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Authorized Official
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Title or Position | OWNER
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Name | SABRINA LUKALU GLOBUS
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Credential |
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Telephone | 612-741-7311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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