Basic Information
Provider Information | |||||||||
NPI: | 1689129868 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONUMENT HEALTH HOME PLUS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONUMENT HEALTH HOME PLUS HOME MEDICAL EQUIPMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 860013 | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554860013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6057557649 | ||||||||
FaxNumber: | 6057557884 | ||||||||
Practice Location | |||||||||
Address1: | 2707 LAZELLE ST | ||||||||
Address2: |   | ||||||||
City: | STURGIS | ||||||||
State: | SD | ||||||||
PostalCode: | 577852934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6057202676 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2016 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TILLES | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT MONUMENT HEALTH HOME PLUS | ||||||||
AuthorizedOfficialTelephone: | 6055191179 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MONUMENT HEALTH HOME PLUS, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.