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General NPI Number Information
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NPI Number | 1821533779
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Entity Type | Organization
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Legal Business Name | MINNEOSTA WELLNESS CENTER LLC
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Dates
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Enumeration Date | 01/02/2017
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Last Update Date | 01/02/2017
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Provider Practice Location Address
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Address Line | 808 BERRY ST APT 192
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City | SAINT PAUL
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State | MN
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Zip | 55114-1082
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Country | US
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Telephone | 612-618-5841
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Fax | 651-646-0950
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Provider Business Mailing Address
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Address Line | 808 BERRY ST APT 192
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City | SAINT PAUL
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State | MN
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Zip | 55114-1082
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Country | US
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Telephone | 612-618-5841
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Fax | 651-646-0950
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Authorized Official
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Title or Position | OWNER
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Name | MRS. UBAH ABUBAKER SHIRWA
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Credential |
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Telephone | 612-618-5841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1083995-1-HCBS
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 1083995-1-HCBS
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License Number State | MN
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