MEDICARE: FUNDAMENTALS AUTISM CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1104619121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNDAMENTALS AUTISM CENTER LLC

Provider Business Mailing Address
First Line	:	1250 MOORE LAKE DR E STE 200
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5136
Country	:	US
Telephone Number	:	206-383-0514
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 MOORE LAKE DR E STE 200
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5136
Country	:	US
Telephone Number	:	206-383-0514
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	HUSSEIN MOHAMED ABSHIR
Credential	:
Telephone Number	:	206-383-0514

Provider Enumeration Date	:	05/22/2025
Last Update Date	:	05/22/2025

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