=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780178970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAXIMAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2018
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1533 UNIVERSITY AVE W STE 110
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-3910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-434-3340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9464 TYNE LN
-----------------------------------------------------
City | INVER GROVE HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55077-4443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AUGUSTINA CHINWE NDUAGU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-434-3340
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------