MEDICARE: GRANDPA & GRANDMA ADULT DAY CARE, INC.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1063020931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANDPA & GRANDMA ADULT DAY CARE, INC.

Provider Business Mailing Address
First Line	:	2518 N 2ND ST STE 116
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2259
Country	:	US
Telephone Number	:	951-564-1131
Fax Number	:

Provider Business Practice Location Address
First Line	:	2518 N 2ND ST STE 116
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2259
Country	:	US
Telephone Number	:	952-564-1311
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FARTUN WELI
Credential	:	MPH
Telephone Number	:	952-564-1131

Provider Enumeration Date	:	07/16/2020
Last Update Date	:	07/16/2020

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