1174610448 NPI number — GUARDIAN ANGELS ELIM HOME CARE, INC

Table of content: DR. BRUCE CARL BROMBERG DC (NPI 1003145137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174610448 NPI number — GUARDIAN ANGELS ELIM HOME CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN ANGELS ELIM HOME CARE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174610448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
403 MAIN ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK RIVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55330-1533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-241-0654
Provider Business Mailing Address Fax Number:
763-241-0274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 MAIN ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELK RIVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55330-1533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-241-0654
Provider Business Practice Location Address Fax Number:
763-241-0274
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JUNG
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
763-241-0654

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  332158 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3153GU . This is a "BCBS/BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 126627600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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