=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700186327
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORGET-ME-NOT HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 10/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 BASS LAKE RD STE. 201
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55429-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-447-7258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1012 MORGAN AVE N
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55411-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-522-0355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | HAZEL H MASUKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-522-0355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 27050
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------