Provenance Homes

Primary specialty

In Home Supportive Care AgencyTaxonomy code 253Z00000X

Legal business name

PROVENANCE HOMES

Doing business as

Provenance Homes

Practice address

1650 W End Blvd Ste 100
St Louis Park, MN 55416-5369

Phone

(612) 261-6988

Fax

(612) 465-1402

NPI assigned

Aug 31, 2023

Last updated

Oct 31, 2023By the provider in NPPES

Organization subpart

Yes

Parent organization

PROVENANCE HEALTHCARE STAFFING LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Sabrina Lukalu Globus

Title

Owner

Phone

(612) 741-7311

Specialties & licenses 2

Addresses

Other names 1

• Provenance Homes Doing business as

Part of

Provenance Homes

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1693440000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698710400000",
    "number": "1285410746",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1650 W END BLVD STE 100",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554165369",
            "telephone_number": "612-261-6988",
            "fax_number": "612-465-1402"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1650 W END BLVD STE 100",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554165369",
            "telephone_number": "612-261-6988",
            "fax_number": "612-465-1402"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5601 Lyndale Ave N",
            "address_purpose": "LOCATION",
            "city": "Brooklyn Center",
            "state": "MN",
            "postal_code": "554303238",
            "country_code": "US",
            "telephone_number": "612-261-6988",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "5547 Lyndale Ave N",
            "address_purpose": "LOCATION",
            "city": "Brooklyn Center",
            "state": "MN",
            "postal_code": "554303237",
            "country_code": "US",
            "telephone_number": "612-261-6988",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PROVENANCE HOMES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROVENANCE HEALTHCARE STAFFING  LLC",
        "enumeration_date": "2023-08-31",
        "last_updated": "2023-10-31",
        "certification_date": "2023-10-24",
        "status": "A",
        "authorized_official_last_name": "GLOBUS",
        "authorized_official_first_name": "SABRINA",
        "authorized_official_middle_name": "LUKALU",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "612-741-7311"
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "253Z00000X",
            "taxonomy_group": "",
            "desc": "In Home Supportive Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Provenance Homes",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Provenance Homes",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• In Home Supportive Care Agency in St Louis Park, MN
• Providers in St Louis Park, MN by specialty
• In Home Supportive Care Agency in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.