1417277054 NPI number — PRAIRIE WINDS WELLNESS, PLLC

Table of content: (NPI 1417277054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417277054 NPI number — PRAIRIE WINDS WELLNESS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE WINDS WELLNESS, PLLC
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:
1417277054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 93
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEOTA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56264-0093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-872-5200
Provider Business Mailing Address Fax Number:
507-872-5236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 E 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEOTA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-872-5200
Provider Business Practice Location Address Fax Number:
507-872-5236
Provider Enumeration Date:
06/06/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VLAMINCK
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
ALLECIA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
507-872-5200

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  1606044 , 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)