1083131643 NPI number — PRIOR LAKE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083131643 NPI number — PRIOR LAKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIOR LAKE
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:
1083131643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14120 COMMERCE AVE NE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRIOR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55372-1503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-447-1080
Provider Business Mailing Address Fax Number:
952-447-0376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14120 COMMERCE AVE
Provider Second Line Business Practice Location Address:
SUITE #300
Provider Business Practice Location Address City Name:
PRIOR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55372-5537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-447-1080
Provider Business Practice Location Address Fax Number:
952-447-0376
Provider Enumeration Date:
08/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SARLES
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
MATTHEW
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
952-447-1080

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  D13230 , 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)





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