=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649677113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE GIVING TREE IN-HOME SENIOR CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2014
-----------------------------------------------------
Last Update Date | 11/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17570 73RD AVE N
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55311-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-889-2429
-----------------------------------------------------
Fax | 763-657-0727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17570 73RD AVE N
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55311-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-889-2429
-----------------------------------------------------
Fax | 763-657-0727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MR. MICHAEL EDWARD O'CONNOR
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 612-889-2429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 29824
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------