Healthcare Provider Details

I. General information

NPI: 1659254274
Provider Name (Legal Business Name): MUSTAFA FARAH (LALD)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3234 DUPONT AVE N
MINNEAPOLIS MN
55412-2510
US

IV. Provider business mailing address

1901 STEVENS AVE APT 2
MINNEAPOLIS MN
55403-3870
US

V. Phone/Fax

Practice location:
  • Phone: 612-836-9799
  • Fax: 612-448-0097
Mailing address:
  • Phone: 612-836-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number1737
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number1737
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number1737
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License Number1737
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: