1801920111 NPI number — CIRCLE OF LIFE HOME CARE ANISHINAABE, LLC

Table of content: (NPI 1801920111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801920111 NPI number — CIRCLE OF LIFE HOME CARE ANISHINAABE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CIRCLE OF LIFE HOME CARE ANISHINAABE, 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:
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:
1801920111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 LEXINGTON AVE N STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHOREVIEW
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55126-3025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-871-2474
Provider Business Mailing Address Fax Number:
612-870-3874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 LEXINGTON AVE N STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOREVIEW
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55126-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-871-2474
Provider Business Practice Location Address Fax Number:
612-870-3874
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FLEURY
Authorized Official First Name:
KATIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
612-871-2474

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  03-091399-00-3 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 05835739 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1801920111 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 233426 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43733034 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18010920111 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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