1285841072 NPI number — BLUE IRIS CENTER FOR THERAPEUTIC SERVICES

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 1285841072 NPI number — BLUE IRIS CENTER FOR THERAPEUTIC SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE IRIS CENTER FOR THERAPEUTIC SERVICES
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:
1285841072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6607 18TH AVE S
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55423-2784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-455-4040
Provider Business Mailing Address Fax Number:
612-455-4041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6607 18TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
RICHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55423-2784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-455-4040
Provider Business Practice Location Address Fax Number:
612-455-4041
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHIKAZAWANELSON
Authorized Official First Name:
GRANT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER THERAPIST
Authorized Official Telephone Number:
612-455-4040

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  0943 , 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: 69B21CH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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