=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790377919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTFUL HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2021
-----------------------------------------------------
Last Update Date | 02/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 SLOAN ST APT 5
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55130-3096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-618-2918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2120 11TH AVE E
-----------------------------------------------------
City | NORTH ST PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-5147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-747-6336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MANAGER
-----------------------------------------------------
Name | MR. LENG XIONG
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 612-618-2918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------