1144749862 NPI number — PARK NICOLLET HEALTH CARE PRODUCTS

Table of content: (NPI 1144749862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144749862 NPI number — PARK NICOLLET HEALTH CARE PRODUCTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK NICOLLET HEALTH CARE PRODUCTS
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:
1144749862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 PARK NICOLLET BLVD # MS 61901C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-2527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
952-993-0562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 RADIO DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-2040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-831-8742
Provider Business Practice Location Address Fax Number:
952-993-0562
Provider Enumeration Date:
09/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BREY
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SUPERVISOR/DELEGATED OFFICIAL
Authorized Official Telephone Number:
952-993-6832

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  6019472 , 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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