1013994532 NPI number — JORI L SHORE

Table of content: JORI L SHORE (NPI 1013994532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013994532 NPI number — JORI L SHORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORE
Provider First Name:
JORI
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1013994532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6465 WAYZATA BLVD
Provider Second Line Business Mailing Address:
STE 315
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55426-1728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-993-7169
Provider Business Mailing Address Fax Number:
952-993-0300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1885 PLAZA DR
Provider Second Line Business Practice Location Address:
PARK NICOLLET CLINIC - EAGAN
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-993-4001
Provider Business Practice Location Address Fax Number:
952-993-4075
Provider Enumeration Date:
12/27/2005

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: 363LF0000X , with the licence number:  9596 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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