1306961511 NPI number — MILK MOMS, INC

Table of content: (NPI 1306961511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306961511 NPI number — MILK MOMS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILK MOMS, INC
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:
1306961511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13783 IBIS ST NW STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55304-7649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-413-0129
Provider Business Mailing Address Fax Number:
763-413-9741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13783 IBIS ST NW STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55304-7649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-413-0129
Provider Business Practice Location Address Fax Number:
763-413-9741
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEGNA
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-413-0129

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 56P99MI . This is a "BC BS PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8200265 . This is a "MEDICA PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 92729 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 040122005 . This is a "PRIME WEST PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 160797 . This is a "UCARE PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 367601300 . This is a "MN DHS PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 040122005 . This is a "MHP PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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