MEDICARE: KIDS ZONE DEVELOPMENT CENTER INC

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1821697202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS ZONE DEVELOPMENT CENTER INC

Provider Business Mailing Address
First Line	:	670 MARIGOLD TER NE
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5641
Country	:	US
Telephone Number	:	161-280-6593
Fax Number	:

Provider Business Practice Location Address
First Line	:	962 UNIVERSITY AVE W
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-4703
Country	:	US
Telephone Number	:	161-280-6593
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FAHMO MOHAMED
Credential	:
Telephone Number	:	612-280-6593

Provider Enumeration Date	:	10/18/2020
Last Update Date	:	12/01/2020

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