1669847075 NPI number — STEVE & BARB JENSEN

Table of content: WILLIAM AARON WILDER MD (NPI 1851145619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669847075 NPI number — STEVE & BARB JENSEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVE & BARB JENSEN
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:
1669847075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36309 AUGUSTANA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56515-9361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-495-2625
Provider Business Mailing Address Fax Number:
218-736-4250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36309 AUGUSTANA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56515-9361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-495-2625
Provider Business Practice Location Address Fax Number:
218-736-4250
Provider Enumeration Date:
12/10/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JENSEN
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-495-2625

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A356977000 . This is a "MN UMIP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".