=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487938437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LJ HOME HEALTH SERVICE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2011
-----------------------------------------------------
Last Update Date | 10/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1990 SUBURBAN AVE SUITE 2008
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55119-7001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-261-4599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6987 COLLINGWOOD LN #6
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-261-4599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MS. LUCY MAE YOUNG
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 651-261-4599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 247276
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------