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General NPI Number Information
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NPI Number | 1629862560
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Entity Type | Organization
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Legal Business Name | HEARTHSIDE CARE LLC
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Dates
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Enumeration Date | 04/07/2025
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Last Update Date | 04/07/2025
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Provider Practice Location Address
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Address Line | 12800 WHITEWATER DR STE 100
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City | MINNETONKA
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State | MN
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Zip | 55343-9347
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Country | US
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Telephone | 962-222-2222
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Fax |
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Provider Business Mailing Address
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Address Line | 12800 WHITEWATER DR STE 100
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City | MINNETONKA
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State | MN
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Zip | 55343-9347
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | AYUB MOHAMED
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Credential |
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Telephone | 952-222-2222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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