1285812412 NPI number — SDS GROUP PA

Table of content: (NPI 1285812412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285812412 NPI number — SDS GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SDS GROUP 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:
CHIROPRACTORS OF ST. ANTHONY / NORTHEAST
Provider Other Organization Name Type Code:
3
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:
1285812412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3813 PLYMOUTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55305-5001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-991-3139
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4833 MINNETONKA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-2214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SALITA
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
612-991-3139

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4370 , 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)

  • Identifier: 787250000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1065328 . This is a "BCBS CLINIC ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 119H8CH . This is a "BCBS MN ID#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com