Healthcare Provider Details

I. General information

NPI: 1477389633
Provider Name (Legal Business Name): PRIME HEALTH WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 10/01/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 LILAC DR N STE 251A
MINNEAPOLIS MN
55422-4535
US

IV. Provider business mailing address

1405 LILAC DR N STE 251A
MINNEAPOLIS MN
55422-4535
US

V. Phone/Fax

Practice location:
  • Phone: 763-344-6351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAD LIBAN JAMA
Title or Position: PRESIDENT
Credential:
Phone: 612-919-1424