Basic Information
| Provider Information | |||||||||
| NPI: | 1104864552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AEDON HOMECARE - MINNESOTA, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASERACARE HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 AMERICAN BLVD W | ||||||||
| Address2: | SUITE 640 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554371108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529430009 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5001 AMERICAN BLVD W | ||||||||
| Address2: | SUITE 640 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554371108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529430009 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | J751 | 01 | UCARE MN | OTHER | 040934100 | 05 | MN | MEDICAID | 183655 | 01 | UCARE MN- HOME HEALTH | OTHER |