Provider Demographics
NPI:1124640339
Name:HOME CARE OF NORTH DAKOTA LLC
Entity type:Organization
Organization Name:HOME CARE OF NORTH DAKOTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT HOME CARE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-4044
Mailing Address - Street 1:2524 S WASHINGTON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6764
Mailing Address - Country:US
Mailing Address - Phone:701-757-4044
Mailing Address - Fax:
Practice Address - Street 1:2524 S WASHINGTON ST STE 5
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6764
Practice Address - Country:US
Practice Address - Phone:701-757-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEWOOD OPCO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-11
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1476888Medicaid