MEDICARE: SUCCESS HOME CARE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1215394655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUCCESS HOME CARE LLC

Provider Business Mailing Address
First Line	:	5701 SHINGLE CREEK PKWY STE 350A
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55430-2485
Country	:	US
Telephone Number	:	763-444-1914
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 SHINGLE CREEK PKWY STE 350A
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55430-2485
Country	:	US
Telephone Number	:	763-444-1914
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OSETOHAMEN ELIZABETH AGENE
Credential	:	RN
Telephone Number	:	763-614-6988

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	01/15/2016

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