Provider Demographics
NPI:1871344523
Name:NORTHEASTERN HOME GROUP LLC
Entity type:Organization
Organization Name:NORTHEASTERN HOME GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FADUMO
Authorized Official - Middle Name:OMAR
Authorized Official - Last Name:JAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-203-2394
Mailing Address - Street 1:716 COUNTY ROAD 10 NE APT 234
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2331
Mailing Address - Country:US
Mailing Address - Phone:612-203-2394
Mailing Address - Fax:
Practice Address - Street 1:10255 GREENBRIER RD APT 122
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3425
Practice Address - Country:US
Practice Address - Phone:612-442-4590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness