Basic Information
| Provider Information | |||||||||
| NPI: | 1275523953 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENNEPIN HOME HEALTH CARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8590 EDINBURGH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554433723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634255959 | ||||||||
| FaxNumber: | 7634255929 | ||||||||
| Practice Location | |||||||||
| Address1: | 8590 EDINBURGH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554433723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634255959 | ||||||||
| FaxNumber: | 7634255929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | MATA | ||||||||
| AuthorizedOfficialFirstName: | AMELIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7634255959 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 328275 | MN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 485717800 | 05 | MN | MEDICAID |