Healthcare Provider Details

I. General information

NPI: 1376301267
Provider Name (Legal Business Name): MS. SADIE VELEKA FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13588 NAGELL CIR
MAPLE GROVE MN
55311-3318
US

IV. Provider business mailing address

2112 BROADWAY ST NE STE 225
MINNEAPOLIS MN
55413-3081
US

V. Phone/Fax

Practice location:
  • Phone: 176-321-9910
  • Fax:
Mailing address:
  • Phone: 763-219-9107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number6NBMUB1WME
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: