MEDICARE: TINA'S HOME CARE AND SERVICES

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1154035889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TINA'S HOME CARE AND SERVICES

Provider Business Mailing Address
First Line	:	2546 CUMBERLAND RD
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-6127
Country	:	US
Telephone Number	:	218-779-9144
Fax Number	:

Provider Business Practice Location Address
First Line	:	2546 CUMBERLAND RD
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-6127
Country	:	US
Telephone Number	:	218-779-9144
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TINA M KEGLER
Credential	:
Telephone Number	:	218-779-9144

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	01/09/2023

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Practice Location Address:

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1639374960 — DR. MANDI LYNN JOHNSON MD
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1578424511 — JENNIFER KAYE MILLS PMHNP
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