1396814281 NPI number — DOUBLE IMAGE, INC

Table of content: (NPI 1396814281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396814281 NPI number — DOUBLE IMAGE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUBLE IMAGE, INC
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:
1396814281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 241509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLE VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55124-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-435-2662
Provider Business Mailing Address Fax Number:
952-435-2624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1056 BURNSVILLE CTR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55306-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-435-2662
Provider Business Practice Location Address Fax Number:
952-435-2624
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
STEPHANNIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-435-2662

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2120188 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3C310PE . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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