Healthcare Provider Details

I. General information

NPI: 1073215497
Provider Name (Legal Business Name): SAMUEL KUO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5228 94TH LN N
BROOKLYN PARK MN
55443-2434
US

IV. Provider business mailing address

5228 94TH LN N
BROOKLYN PARK MN
55443-2434
US

V. Phone/Fax

Practice location:
  • Phone: 612-695-5091
  • Fax:
Mailing address:
  • Phone: 608-628-6128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1118231
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: