Provider Demographics
NPI:1447073457
Name:BOURALEH, ABDIKADAR
Entity type:Individual
Prefix:
First Name:ABDIKADAR
Middle Name:
Last Name:BOURALEH
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 1:75 TWIN LAKE BLVD APT 114
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55127-4039
Mailing Address - Country:US
Mailing Address - Phone:207-440-8021
Mailing Address - Fax:763-374-8511
Practice Address - Street 1:75 TWIN LAKE BLVD APT 114
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55127-4039
Practice Address - Country:US
Practice Address - Phone:207-440-8021
Practice Address - Fax:763-374-8511
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN385117343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)