MEDICARE: 12TH HOUSE HEALING SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	177F00000X	Lodging Provider
2	253Z00000X	In Home Supportive Care Agency
3	3104A0625X	Assisted Living Facility (Mental Illness)
4	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
5	320800000X	Mental Illness Community Based Residential Treatment Facility
6	251J00000X	Nursing Care Agency

General Provider Information

NPI Number	:	1871367714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	12TH HOUSE HEALING SERVICES

Provider Business Mailing Address
First Line	:	650 AGUIRRE ST APT 232
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-4430
Country	:	US
Telephone Number	:	612-584-0902
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 AGUIRRE ST APT 232
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-4430
Country	:	US
Telephone Number	:	612-584-0902
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. TAYONNA MARTIA MAYS
Credential	:	RN
Telephone Number	:	612-584-0902

Provider Enumeration Date	:	11/10/2023
Last Update Date	:	11/10/2023

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