Provider Demographics
NPI:1639790512
Name:STAMBOULIEH, ELIA
Entity Type:Individual
Prefix:MR
First Name:ELIA
Middle Name:
Last Name:STAMBOULIEH
Suffix:
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 1:2777 LEXINGTON AVE,
Mailing Address - Street 2:UNIT D
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2013
Mailing Address - Country:US
Mailing Address - Phone:206-372-8877
Mailing Address - Fax:
Practice Address - Street 1:2777 LEXINGTON AVE,
Practice Address - Street 2:UNIT D
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2013
Practice Address - Country:US
Practice Address - Phone:206-372-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty