Healthcare Provider Details

I. General information

NPI: 1194067389
Provider Name (Legal Business Name): SURFACE SPECIALISTS METRO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 EXCELSIOR BLVD SUITE #414
ST LOUIS PARK MN
55416-2906
US

IV. Provider business mailing address

5115 EXCELSIOR BLVD SUITE #414
ST LOUIS PARK MN
55416-2906
US

V. Phone/Fax

Practice location:
  • Phone: 763-753-2807
  • Fax: 763-444-7980
Mailing address:
  • Phone: 763-753-2807
  • Fax: 763-444-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberIR651456
License Number StateMN

VIII. Authorized Official

Name: MERRI ROOS
Title or Position: VICE PRESIDENT
Credential:
Phone: 763-753-2807