=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407534886
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDEMPTION PCA SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2023
-----------------------------------------------------
Last Update Date | 07/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 BASS LAKE RD STE 120
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-406-0577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6000 BASS LAKE RD STE 120
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-406-0577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. SAMON DAWON BAHTUOH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-406-0577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------