1336359009 NPI number — UNITY FAMILY HEALTHCARE

Table of content: (NPI 1336359009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336359009 NPI number — UNITY FAMILY HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNITY FAMILY HEALTHCARE
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:
RANDALL LAKES AREA CLINIC
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:
1336359009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 WHITE OAK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDALL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-749-2877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 WHITE OAK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANDALL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-749-2877
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
320-631-5670

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 640K9RA . This is a "BCBSM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 040760700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24-3447 . This is a "RHC PROVIDER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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