1104911676 NPI number — DR. LARAINE PATRICIA KURISKO PH.D., LP

Table of content: DR. LARAINE PATRICIA KURISKO PH.D., LP (NPI 1104911676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104911676 NPI number — DR. LARAINE PATRICIA KURISKO PH.D., LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KURISKO
Provider First Name:
LARAINE
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., LP
Provider Gender Code:
F

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:
1104911676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18664 OVERLAND TRAIL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55347-4186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-974-3764
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4005 WEST 65TH STREET
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-926-2424
Provider Business Practice Location Address Fax Number:
952-926-3454
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP4466 , 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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