Healthcare Provider Details

I. General information

NPI: 1982935854
Provider Name (Legal Business Name): ABDI GALGALO GONJOBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 BURKE CIR E
MAPLEWOOD MN
55109-3450
US

IV. Provider business mailing address

1312 BURKE CIR E
MAPLEWOOD MN
55109-3450
US

V. Phone/Fax

Practice location:
  • Phone: 651-230-9300
  • Fax: 651-739-1269
Mailing address:
  • Phone: 651-230-9300
  • Fax: 651-739-1269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number347084
License Number StateMN

VIII. Authorized Official

Name: DR. ABDI GALGALO GONJOBE
Title or Position: PRESIDENT /CEO
Credential: M.D.
Phone: 651-230-9300