MEDICARE: DIVERSITY WELLNESS 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1487489662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSITY WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	1405 LILAC DR N STE 150G
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4536
Country	:	US
Telephone Number	:	612-598-2515
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 LILAC DR N STE 150G
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4536
Country	:	US
Telephone Number	:	612-598-2515
Fax Number	:	612-808-1814

Authorized Official
Title or Position	:	OWNER
Name	:	MAYMUNA ABDULKADIR MOHAMUD
Credential	:
Telephone Number	:	612-598-2515

Provider Enumeration Date	:	09/05/2024
Last Update Date	:	06/21/2026

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Directions to “DIVERSITY WELLNESS CENTER LLC ” Practice Location

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