=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912207556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO MEDICAL SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 03/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14697 80TH PL N STE ML
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55311-2154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-390-2561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14697 80TH PL N STE #ML P O BOX 1681
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55311-6681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-390-2561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED AGENT / OFFICIAL
-----------------------------------------------------
Name | ANTHONY ADANENE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-390-2590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------