Provider Demographics
NPI:1659120830
Name:HOMEBASE SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:HOMEBASE SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-831-8710
Mailing Address - Street 1:14889 NOKAY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-5595
Mailing Address - Country:US
Mailing Address - Phone:218-831-8710
Mailing Address - Fax:
Practice Address - Street 1:14889 NOKAY LAKE RD
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-5595
Practice Address - Country:US
Practice Address - Phone:218-831-8710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOMEBASE HOUSING SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-18
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty