=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114674660
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. RAJESH MEHTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2022
-----------------------------------------------------
Last Update Date | 03/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 ROBERT ST S STE 102
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55107-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-805-8008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 ROBERT ST S STE 102
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55107-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-805-8008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 1094266
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------