Healthcare Provider Details

I. General information

NPI: 1942739347
Provider Name (Legal Business Name): CABDICASIIS CILMI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 28TH AVE N SUITE J
SAINT CLOUD MN
56303
US

IV. Provider business mailing address

44 28TH AVE N STE J
SAINT CLOUD MN
56303-4259
US

V. Phone/Fax

Practice location:
  • Phone: 612-876-5503
  • Fax:
Mailing address:
  • Phone: 612-876-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number163WH0200X
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: