Provider Demographics
NPI:1912427782
Name:AHELEGBE, KWAO GARETH (LAC)
Entity type:Individual
Prefix:
First Name:KWAO
Middle Name:GARETH
Last Name:AHELEGBE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:305 COTTAGE AVE W APT 312
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4388
Mailing Address - Country:US
Mailing Address - Phone:612-248-4670
Mailing Address - Fax:
Practice Address - Street 1:6311 WAYZATA BLVD STE 240
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2683
Practice Address - Country:US
Practice Address - Phone:952-545-6408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist