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General NPI Number Information
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NPI Number | 1992521116
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Entity Type | Organization
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Legal Business Name | SOUTH LAKE AUTISM CENTER L. L. C.
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Dates
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Enumeration Date | 12/03/2024
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Last Update Date | 02/17/2025
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Provider Practice Location Address
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Address Line | 2147 UNIVERSITY AVE W STE 109
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City | SAINT PAUL
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State | MN
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Zip | 55114-1326
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Country | US
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Telephone | 617-992-1536
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Fax |
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Provider Business Mailing Address
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Address Line | 2147 UNIVERSITY AVE W STE 108
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City | SAINT PAUL
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State | MN
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Zip | 55114-1326
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Country | US
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Telephone | 617-992-1536
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHIKHDOON JAMA WARSAME
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Credential |
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Telephone | 617-992-1536
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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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