Healthcare Provider Details

I. General information

NPI: 1114674660
Provider Name (Legal Business Name): MR. RAJESH MEHTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ROBERT ST S STE 102
SAINT PAUL MN
55107-1626
US

IV. Provider business mailing address

220 ROBERT ST S STE 102
SAINT PAUL MN
55107-1626
US

V. Phone/Fax

Practice location:
  • Phone: 612-805-8008
  • Fax:
Mailing address:
  • Phone: 612-805-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1094266
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: