Healthcare Provider Details

I. General information

NPI: 1588009732
Provider Name (Legal Business Name): BLUE & WHITE SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 PARK GLEN RD
SAINT LOUIS PARK MN
55416-5702
US

IV. Provider business mailing address

4812 PARK GLEN RD
SAINT LOUIS PARK MN
55413-4605
US

V. Phone/Fax

Practice location:
  • Phone: 612-333-0469
  • Fax: 612-236-0544
Mailing address:
  • Phone: 612-333-0469
  • Fax: 612-236-0544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State

VIII. Authorized Official

Name: MR. WALEED SONBOL
Title or Position: GENERAL MANAGER
Credential:
Phone: 612-669-7389