1306350178 NPI number — LIVING HOPE SECOND CHANCE LLC

Table of content: BOB HANDELMAN (NPI 1528044179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306350178 NPI number — LIVING HOPE SECOND CHANCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING HOPE SECOND CHANCE LLC
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:
PRO-SERVICES PROFESSINAL SERVICES
Provider Other Organization Name Type Code:
3
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:
1306350178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20455 CYPRESS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55024-7319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-203-4535
Provider Business Mailing Address Fax Number:
952-217-4427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7400 METRO BLVD STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55439-2352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-203-4535
Provider Business Practice Location Address Fax Number:
952-217-4427
Provider Enumeration Date:
11/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
TAVIA
Authorized Official Middle Name:
LYNNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
612-203-4535

Provider Taxonomy Codes

  • Taxonomy code: 174200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 342000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2055X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 405300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1306350178 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1306350178 . This is a "ANY HEALTHCARE RELATED IDENTIFIERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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