Healthcare Provider Details

I. General information

NPI: 1457753998
Provider Name (Legal Business Name): ELITE TAXI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 5TH ST N
SAINT CLOUD MN
56303-3924
US

IV. Provider business mailing address

1415 5TH ST N
SAINT CLOUD MN
56303-3924
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-2999
  • Fax:
Mailing address:
  • Phone: 320-240-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberE335037292511
License Number StateMN

VIII. Authorized Official

Name: WILLIAM BAKER
Title or Position: OWNER
Credential:
Phone: 320-240-2999