1538247416 NPI number — THE WINKLEY COMPANY

Table of content: CELIE MARIE VAUGHN RD (NPI 1770627325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538247416 NPI number — THE WINKLEY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WINKLEY COMPANY
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:
1538247416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 DOUGLAS DR N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDEN VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55422-4301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-546-1177
Provider Business Mailing Address Fax Number:
763-847-9508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3960 COON RAPIDS BLVD
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-421-3587
Provider Business Practice Location Address Fax Number:
763-506-9905
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRUMAN
Authorized Official First Name:
ALEXANDER
Authorized Official Middle Name:
PETER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
763-546-1177

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  NONE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 214488000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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