Healthcare Provider Details

I. General information

NPI: 1154932507
Provider Name (Legal Business Name): MOHAMUD B HABIB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MOHAMUD BANA HABIB

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 OAKWOOD MALL DR 200
EAU CLAIRE WI
54701
US

IV. Provider business mailing address

3402 OAKWOOD MALL DR
EAU CLAIRE WI
54701-2807
US

V. Phone/Fax

Practice location:
  • Phone: 612-402-0211
  • Fax:
Mailing address:
  • Phone: 612-402-0211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number1166222100027
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: