=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376431205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINDHEART HEALTHCARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2025
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 MENDELSSOHN AVE N STE 104C
-----------------------------------------------------
City | GOLDEN VALLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55427-4376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-998-6012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 MENDELSSOHN AVE N STE 104C
-----------------------------------------------------
City | GOLDEN VALLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55427-4376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-998-6012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NIMO AW IBRAHIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-998-6012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------