1730542572 NPI number — IRIS REPRODUCTIVE PSYCHIATRIC CLINIC

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 1730542572 NPI number — IRIS REPRODUCTIVE PSYCHIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IRIS REPRODUCTIVE PSYCHIATRIC CLINIC
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:
1730542572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 MCANDREWS RD W
Provider Second Line Business Mailing Address:
227
Provider Business Mailing Address City Name:
BURNSVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55337-4432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-406-4747
Provider Business Mailing Address Fax Number:
612-437-4759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 MCANDREWS ROAD W
Provider Second Line Business Practice Location Address:
STE 227
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-406-4747
Provider Business Practice Location Address Fax Number:
612-437-4759
Provider Enumeration Date:
03/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HUGUELET
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER/OPERATER
Authorized Official Telephone Number:
860-406-4747

Provider Taxonomy Codes

  • Taxonomy code: 364SP0808X , with the licence number:  R134588-7 , 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: 168946100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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