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General NPI Number Information
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NPI Number | 1841966116
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Entity Type | Organization
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Legal Business Name | PROVISIONAL HEALTH AND REHABILITATIVE SERVICES LLC
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Dates
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Enumeration Date | 08/18/2021
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Last Update Date | 02/12/2026
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Provider Practice Location Address
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Address Line | 4111 CENTRAL AVE NE STE 208B
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City | COLUMBIA HEIGHTS
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State | MN
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Zip | 55421-2955
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Country | US
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Telephone | 763-205-3258
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Fax |
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Provider Business Mailing Address
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Address Line | 4111 CENTRAL AVE NE STE 208B
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City | COLUMBIA HEIGHTS
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State | MN
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Zip | 55421-2955
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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 | OWNER
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Name | ALI JAMA
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Credential |
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Telephone | 952-687-9064
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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