=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831634807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERSON, INC. HOME CARE PCA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2016
-----------------------------------------------------
Last Update Date | 12/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 639 PROVIDENCE DR BOX 7
-----------------------------------------------------
City | SHAKOPEE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55379-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-707-2430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 639 PROVIDENCE DR BOX 7
-----------------------------------------------------
City | SHAKOPEE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55379-4550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-707-2430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOSEPH A. ROBERSON SR.
-----------------------------------------------------
Credential | PCA
-----------------------------------------------------
Telephone | 612-707-2430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | PCA57407320161127
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------