MEDICARE: BLUE & WHITE SERVICE CORPORATION

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	344600000X	Taxi

General Provider Information

NPI Number	:	1588009732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE & WHITE SERVICE CORPORATION

Provider Business Mailing Address
First Line	:	4812 PARK GLEN RD
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55413-4605
Country	:	US
Telephone Number	:	612-333-0469
Fax Number	:	612-236-0544

Provider Business Practice Location Address
First Line	:	4812 PARK GLEN RD
Second Line	:
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-5702
Country	:	US
Telephone Number	:	612-333-0469
Fax Number	:	612-236-0544

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. WALEED SONBOL
Credential	:
Telephone Number	:	612-669-7389

Provider Enumeration Date	:	05/01/2013
Last Update Date	:	08/14/2015

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