Provider Demographics
NPI:1992285233
Name:OUR FAMILY HOME LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:OUR FAMILY HOME LIMITED LIABILITY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PERKALOAH
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:QUEEGLAY-TARPEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-387-6629
Mailing Address - Street 1:3300 COUNTY ROAD 10 STE 512I
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3068
Mailing Address - Country:US
Mailing Address - Phone:763-273-4381
Mailing Address - Fax:763-717-8304
Practice Address - Street 1:3300 COUNTY ROAD 10 STE 512I
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3068
Practice Address - Country:US
Practice Address - Phone:763-273-4381
Practice Address - Fax:763-717-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========Medicaid