MEDICARE: AQUAD WELLNESS GROUP 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1376378059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUAD WELLNESS GROUP LLC

Provider Business Mailing Address
First Line	:	10805 173RD ST W APT 228
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-5341
Country	:	US
Telephone Number	:	612-669-3904
Fax Number	:

Provider Business Practice Location Address
First Line	:	6482 BARCLAY AVE
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55077-2165
Country	:	US
Telephone Number	:	612-669-3904
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ABDIWELI MOHAMED ELMI
Credential	:
Telephone Number	:	612-669-3904

Provider Enumeration Date	:	09/03/2024
Last Update Date	:	09/27/2024

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