1497707426 NPI number — KINGSWOOD ENTERPRISES, LLC

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 1497707426 NPI number — KINGSWOOD ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSWOOD ENTERPRISES, LLC
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:
NEB DOCTORS OF MN
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:
1497707426
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4131 OLD SIBLEY MEMORIAL HWY
Provider Second Line Business Mailing Address:
STE. 203
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-1947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-876-4057
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4131 OLD SIBLEY MEMORIAL HWY
Provider Second Line Business Practice Location Address:
STE. 203
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-1947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-876-4057
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCDONALD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
952-876-4057

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: 692682700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 181270 . This is a "GROUP U-CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".