MEDICARE: FORTUNATE HOMES 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	:	1508372426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTUNATE HOMES LLC

Provider Business Mailing Address
First Line	:	10875 131ST AVE N
Second Line	:
City	:	CHAMPLIN
State	:	MN
Zip	:	55316-1139
Country	:	US
Telephone Number	:	952-674-7774
Fax Number	:

Provider Business Practice Location Address
First Line	:	7409 LOUISIANA AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-1230
Country	:	US
Telephone Number	:	952-994-5356
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	SUSAN OBWAYA
Credential	:
Telephone Number	:	952-994-5356

Provider Enumeration Date	:	12/15/2017
Last Update Date	:	09/11/2023

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Directions to “FORTUNATE HOMES LLC ” Practice Location

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