Provider Demographics
NPI:1821533779
Name:MINNEOSTA WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:MINNEOSTA WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:UBAH
Authorized Official - Middle Name:ABUBAKER
Authorized Official - Last Name:SHIRWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-618-5841
Mailing Address - Street 1:808 BERRY ST APT 192
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1082
Mailing Address - Country:US
Mailing Address - Phone:612-618-5841
Mailing Address - Fax:651-646-0950
Practice Address - Street 1:808 BERRY ST APT 192
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1082
Practice Address - Country:US
Practice Address - Phone:612-618-5841
Practice Address - Fax:651-646-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1083995-1-HCBS251S00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No251S00000XAgenciesCommunity/Behavioral Health