Provider Demographics
NPI:1558759647
Name:OMAR, ABDULKADIR ALI SR
Entity Type:Individual
Prefix:
First Name:ABDULKADIR
Middle Name:ALI
Last Name:OMAR
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 EDINA INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2910
Mailing Address - Country:US
Mailing Address - Phone:952-652-4109
Mailing Address - Fax:612-886-2618
Practice Address - Street 1:5245 EDINA INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2910
Practice Address - Country:US
Practice Address - Phone:612-472-5645
Practice Address - Fax:612-886-2618
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-26
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician