Healthcare Provider Details

I. General information

NPI: 1225693690
Provider Name (Legal Business Name): HUSEN SALAH ROBLEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 1ST AVE S
MINNEAPOLIS MN
55408-1601
US

IV. Provider business mailing address

2612 1ST AVE S
MINNEAPOLIS MN
55408-1601
US

V. Phone/Fax

Practice location:
  • Phone: 612-249-6463
  • Fax: 612-254-8538
Mailing address:
  • Phone: 612-249-6463
  • Fax: 612-254-8538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number1096049-1-ADC
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: