1396748307 NPI number — LIFESCAN MINNESOTA LLC

Table of content: (NPI 1396748307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396748307 NPI number — LIFESCAN MINNESOTA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESCAN MINNESOTA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396748307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3955 PARKLAWN AVE
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-5657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-893-1997
Provider Business Mailing Address Fax Number:
952-893-0088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3955 PARKLAWN AVE
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-5657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-893-1997
Provider Business Practice Location Address Fax Number:
952-893-0088
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOUGLAS
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
502-403-1401

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9146652-00 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".