MEDICARE: BRIGHT LAKE 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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1760203517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHT LAKE CARE LLC

Provider Business Mailing Address
First Line	:	3845 HIAWATHA AVE APT 509
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-4454
Country	:	US
Telephone Number	:	612-800-4209
Fax Number	:

Provider Business Practice Location Address
First Line	:	3845 HIAWATHA AVE APT 509
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-4454
Country	:	US
Telephone Number	:	612-800-4209
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TARIQ ALI
Credential	:
Telephone Number	:	612-800-4209

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	05/13/2025

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