1043860109 NPI number — ST. CLOUD NEUROBEHAVIORAL ASSOCIATES, PA

Table of content: (NPI 1043860109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043860109 NPI number — ST. CLOUD NEUROBEHAVIORAL ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. CLOUD NEUROBEHAVIORAL ASSOCIATES, PA
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:
1043860109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-0230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-253-3833
Provider Business Mailing Address Fax Number:
320-253-5741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3812 8TH ST N STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-1421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-253-3833
Provider Business Practice Location Address Fax Number:
320-253-5741
Provider Enumeration Date:
09/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
VOGEL
Authorized Official First Name:
ANNIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
320-253-3833

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C03196 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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