MEDICARE: MISSISSIPPI HOME HEALTH 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1841781317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSISSIPPI HOME HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	2718 NICOLLET AVE STE 205
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-1648
Country	:	US
Telephone Number	:	612-876-1274
Fax Number	:	612-888-9450

Provider Business Practice Location Address
First Line	:	2718 NICOLLET AVE STE 205
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-1648
Country	:	US
Telephone Number	:	612-876-1274
Fax Number	:	952-888-9450

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MOHAMED IDIRIS ISMAIL
Credential	:
Telephone Number	:	612-876-1274

Provider Enumeration Date	:	05/21/2018
Last Update Date	:	09/10/2019

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