MEDICARE: GLORY HOME HEALTH, 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	251E00000X	Home Health Agency	381828	MN

General Provider Information

NPI Number	:	1285157768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLORY HOME HEALTH, INC

Provider Business Mailing Address
First Line	:	1913 BROADWAY ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2627
Country	:	US
Telephone Number	:	612-354-7791
Fax Number	:	612-886-2567

Provider Business Practice Location Address
First Line	:	1913 BROADWAY ST NE STE 100
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2627
Country	:	US
Telephone Number	:	612-354-7791
Fax Number	:	612-886-2567

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	NASRO MOHAMED
Credential	:	RN
Telephone Number	:	612-707-0905

Provider Enumeration Date	:	07/17/2017
Last Update Date	:	10/11/2018

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