Provider Demographics
NPI:1295347854
Name:SHINING LIGHT SKILL BUILDING LLC
Entity type:Organization
Organization Name:SHINING LIGHT SKILL BUILDING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:CALI
Authorized Official - Last Name:ADAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-978-0760
Mailing Address - Street 1:3055 OLD HIGHWAY 8 STE 106B
Mailing Address - Street 2:
Mailing Address - City:ST. ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418
Mailing Address - Country:US
Mailing Address - Phone:612-978-0760
Mailing Address - Fax:
Practice Address - Street 1:3055 OLD HIGHWAY 8 STE 106B
Practice Address - Street 2:
Practice Address - City:ST. ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418
Practice Address - Country:US
Practice Address - Phone:612-978-0760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty