Healthcare Provider Details

I. General information

NPI: 1669207478
Provider Name (Legal Business Name): BLUE STAR SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 12TH AVE N APT 212
SAINT CLOUD MN
56303-3588
US

IV. Provider business mailing address

625 12TH AVE N APT 212
SAINT CLOUD MN
56303-3588
US

V. Phone/Fax

Practice location:
  • Phone: 320-217-5048
  • Fax: 320-295-7862
Mailing address:
  • Phone: 320-217-5048
  • Fax: 320-295-7862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ABDIGANI AHMED
Title or Position: OWNER
Credential:
Phone: 320-217-5048