Healthcare Provider Details

I. General information

NPI: 1447073457
Provider Name (Legal Business Name): ABDIKADAR BOURALEH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 TWIN LAKE BLVD APT 114
LITTLE CANADA MN
55127-4039
US

IV. Provider business mailing address

75 TWIN LAKE BLVD APT 114
LITTLE CANADA MN
55127-4039
US

V. Phone/Fax

Practice location:
  • Phone: 207-440-8021
  • Fax: 763-374-8511
Mailing address:
  • Phone: 207-440-8021
  • Fax: 763-374-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number385117
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: