1467673715 NPI number — MR. TODD MICHAEL WESTLAKE CPO

Table of content: MR. TODD MICHAEL WESTLAKE CPO (NPI 1467673715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467673715 NPI number — MR. TODD MICHAEL WESTLAKE CPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WESTLAKE
Provider First Name:
TODD
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CPO
Provider Gender Code:
M

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:
1467673715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22990 FAWN TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55374-8740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-428-5453
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 24TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55454-1455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-672-6653
Provider Business Practice Location Address Fax Number:
612-672-4780
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X , with the licence number:  CPO 1904 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 224P00000X , with the licence number: CPO 1904 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 077842 . This is a "FAIRVIEW HEATH SERVICES #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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