1346653052 NPI number — ADVANCED SPINE AND PAIN CLINICS OF MN, LLC

Table of content: (NPI 1346653052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346653052 NPI number — ADVANCED SPINE AND PAIN CLINICS OF MN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SPINE AND PAIN CLINICS OF MN, LLC
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:
1346653052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7373 FRANCE AVE
Provider Second Line Business Mailing Address:
SUITE 606
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-4552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-207-7463
Provider Business Mailing Address Fax Number:
952-831-0276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 BRIGHTON AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55313-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-595-1411
Provider Business Practice Location Address Fax Number:
763-595-1412
Provider Enumeration Date:
06/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
THORSON
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MD/PRESIDENT
Authorized Official Telephone Number:
612-207-7463

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , 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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