1528040169 NPI number — INTREPID OF GOLDEN VALLEY INC

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 1528040169 NPI number — INTREPID OF GOLDEN VALLEY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTREPID OF GOLDEN VALLEY 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:
6
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:
1528040169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14841 DALLAS PKWY STE 625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75254-7641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-445-3750
Provider Business Mailing Address Fax Number:
214-445-3902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7300 METRO BLVD
Provider Second Line Business Practice Location Address:
SUITE 625
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55439-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-513-5400
Provider Business Practice Location Address Fax Number:
952-513-5444
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PARKER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CCO
Authorized Official Telephone Number:
214-445-3750

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  326853 CLASS A , 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: 851755000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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