MEDICARE: RALIANCE GROUP HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1053176149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALIANCE GROUP HOME LLC

Provider Business Mailing Address
First Line	:	2618 LONGFELLOW AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1230
Country	:	US
Telephone Number	:	612-702-4834
Fax Number	:

Provider Business Practice Location Address
First Line	:	2618 LONGFELLOW AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1230
Country	:	US
Telephone Number	:	612-702-4834
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	FADIL ALI
Credential	:
Telephone Number	:	612-702-4834

Provider Enumeration Date	:	02/16/2024
Last Update Date	:	02/16/2024

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