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General NPI Number Information
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NPI Number | 1336790864
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Entity Type | Organization
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Legal Business Name | MECCA MEDICAL CENTER, LLC
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Dates
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Enumeration Date | 09/25/2019
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Last Update Date | 02/20/2020
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Provider Practice Location Address
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Address Line | 309 E COLLEGE DR
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City | MARSHALL
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State | MN
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Zip | 56258-2379
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Country | US
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Telephone | 507-530-6028
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Fax |
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Provider Business Mailing Address
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Address Line | 1120 BIRCH ST APT 2
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City | MARSHALL
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State | MN
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Zip | 56258-1550
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | IDRISS IBRAHIM
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Credential | NP
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Telephone | 507-530-6028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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