1558719393 NPI number — FOUNDATION INTERESTS GROUP, P.C.

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 1558719393 NPI number — FOUNDATION INTERESTS GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNDATION INTERESTS GROUP, P.C.
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:
1558719393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
835 40TH ST NW
Provider Second Line Business Mailing Address:
SUITE 217
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55901-4248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 2ND ST SW
Provider Second Line Business Practice Location Address:
SUITE 125
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55902-4156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-320-1555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MICKELSON
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
507-320-1555

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5904 , 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)





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