1679863773 NPI number — PAIN RELIEF AND WELLNESS OF MINNESOTA

Table of content: (NPI 1679863773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679863773 NPI number — PAIN RELIEF AND WELLNESS OF MINNESOTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN RELIEF AND WELLNESS OF MINNESOTA
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:
1679863773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4721 CLARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-3221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-788-6689
Provider Business Mailing Address Fax Number:
651-560-7013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4721 CLARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-249-0454
Provider Business Practice Location Address Fax Number:
651-560-7013
Provider Enumeration Date:
04/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKETZ
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
JASON
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
651-249-0454

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34536300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 530615900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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