1386374593 NPI number — PRIMARY ENT, L.L.C.

Table of content: (NPI 1386374593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386374593 NPI number — PRIMARY ENT, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY ENT, L.L.C.
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:
6
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:
1386374593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6021 NORTHWOOD RDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55438-1282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-406-9966
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14020 HWY 13 S STE 350
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVAGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55378-7103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-395-2500
Provider Business Practice Location Address Fax Number:
952-395-2501
Provider Enumeration Date:
06/13/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BOONE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
LUTHER
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
612-406-9966

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207YX0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1609035781 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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