=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659942993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPECARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2021
-----------------------------------------------------
Last Update Date | 07/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3818 61ST AVE N
-----------------------------------------------------
City | BROOKLYN CENTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-202-6770
-----------------------------------------------------
Fax | 952-516-5152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12331 PINERIDGE WAY N
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55327-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-202-6770
-----------------------------------------------------
Fax | 952-516-5152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL RN
-----------------------------------------------------
Name | PENNINNAH KERUBO OBWAYA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-202-6770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------