Healthcare Provider Details

I. General information

NPI: 1003711268
Provider Name (Legal Business Name): NOVA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5275 EDINA INDUSTRIAL BLVD STE 230
EDINA MN
55439-2912
US

IV. Provider business mailing address

5275 EDINA INDUSTRIAL BLVD STE 230
EDINA MN
55439-2912
US

V. Phone/Fax

Practice location:
  • Phone: 252-469-0022
  • Fax:
Mailing address:
  • Phone: 252-469-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. AHMED JAMA
Title or Position: DIRECTOR
Credential:
Phone: 252-469-0022