Healthcare Provider Details

I. General information

NPI: 1750888335
Provider Name (Legal Business Name): GOULD ENTERPRISE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 BURNS AVE STE B
SAINT PAUL MN
55119
US

IV. Provider business mailing address

1995 BURNS AVE STE B
SAINT PAUL MN
55119-4906
US

V. Phone/Fax

Practice location:
  • Phone: 651-739-5173
  • Fax: 651-739-8907
Mailing address:
  • Phone: 651-739-5173
  • Fax: 651-739-8907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SOLOMON M GOULD
Title or Position: OWNER
Credential:
Phone: 651-739-5173