=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215795745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STABLE SPACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2024
-----------------------------------------------------
Last Update Date | 03/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 548 LOMIANKI LN NE
-----------------------------------------------------
City | COLUMBIA HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55421-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-410-7615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 548 LOMIANKI LN NE
-----------------------------------------------------
City | COLUMBIA HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55421-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-410-7615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YASIN BUNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-410-7615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------