Healthcare Provider Details

I. General information

NPI: 1346186806
Provider Name (Legal Business Name): POULO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20328 PRAIRIE DR
BIG LAKE MN
55309-4808
US

IV. Provider business mailing address

20328 PRAIRIE DR
BIG LAKE MN
55309-4808
US

V. Phone/Fax

Practice location:
  • Phone: 917-690-2357
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name: OUSMANE SOW
Title or Position: OWNER
Credential:
Phone: 191-769-0235