Healthcare Provider Details

I. General information

NPI: 1952843864
Provider Name (Legal Business Name): SOUTH METRO HUMAN SERVICES-ACT BLUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 4TH ST E SUITE 200
SAINT PAUL MN
55101-1421
US

IV. Provider business mailing address

166 4TH ST E SUITE 200
SAINT PAUL MN
55101-1421
US

V. Phone/Fax

Practice location:
  • Phone: 651-389-4690
  • Fax: 651-389-4691
Mailing address:
  • Phone: 651-389-4690
  • Fax: 651-389-4691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: TOM PAUL
Title or Position: PRESIDENT
Credential:
Phone: 651-256-1234