MEDICARE: SPECTRUM SOLUTION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1457107575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM SOLUTION LLC

Provider Business Mailing Address
First Line	:	3055 OLD HIGHWAY 8 STE 111
Second Line	:
City	:	SAINT ANTHONY
State	:	MN
Zip	:	55418-2577
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3055 OLD HIGHWAY 8 STE 111
Second Line	:
City	:	SAINT ANTHONY
State	:	MN
Zip	:	55418-2577
Country	:	US
Telephone Number	:	612-986-2089
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ISMAHAN YUSUF
Credential	:
Telephone Number	:	612-986-2089

Provider Enumeration Date	:	04/29/2024
Last Update Date	:	04/29/2024

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