1407869662 NPI number — NORTHERN STAR THERAPY LTD

Table of content: (NPI 1407869662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407869662 NPI number — NORTHERN STAR THERAPY LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN STAR THERAPY LTD
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:
1407869662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 COUNTY RD 120
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-259-5429
Provider Business Mailing Address Fax Number:
320-240-8905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 19TH ST S
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-257-2225
Provider Business Practice Location Address Fax Number:
320-257-2226
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEAVER
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
320-240-6955

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 748070900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 264M1NO . This is a "BLUE CROSS BLUE SHIELD OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6B481NO . This is a "BLUE CROSS BLUE SHIELD OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 4G183NO . This is a "BLUE CROSS BLUE SHIELD OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 234211100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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