Provider Demographics
NPI:1407364813
Name:IMMACULATE HOME CARE LLC
Entity type:Organization
Organization Name:IMMACULATE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KAYODE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAIWO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-670-5597
Mailing Address - Street 1:3731 IDAHO AVENUE EAST
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106
Mailing Address - Country:US
Mailing Address - Phone:651-666-2135
Mailing Address - Fax:651-666-2137
Practice Address - Street 1:3731 IDAHO AVENUE EAST
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106
Practice Address - Country:US
Practice Address - Phone:651-666-2135
Practice Address - Fax:651-666-2137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-19
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health