1598150930 NPI number — NOVA BHS

Table of content: (NPI 1598150930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598150930 NPI number — NOVA BHS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVA BHS
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:
MARYANNE LASSEGARD
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:
1598150930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 INTERLACHEN DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAM LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-306-4721
Provider Business Mailing Address Fax Number:
763-434-6570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 TANGLEWOOD DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOREVIEW
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-306-4721
Provider Business Practice Location Address Fax Number:
763-434-6570
Provider Enumeration Date:
04/02/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LASSEGARD
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
612-306-4721

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X , with the licence number:  LP2187 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: LP2187 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TH0100X , with the licence number: LP2187 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP2701X , with the licence number: LP2187 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: LP2187 , 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)