1689682155 NPI number — ANN E BOEKHOFF MA LP PA

Table of content: (NPI 1689682155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689682155 NPI number — ANN E BOEKHOFF MA LP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANN E BOEKHOFF MA LP PA
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:
1689682155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
91 N SNELLING AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104-6756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-647-3492
Provider Business Mailing Address Fax Number:
651-641-1074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 N SNELLING AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-6756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-647-3492
Provider Business Practice Location Address Fax Number:
651-641-1074
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOEKHOFF
Authorized Official First Name:
ANN
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
OWNER SOLE PROPRIETOR
Authorized Official Telephone Number:
651-647-3492

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP1197 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 334 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 57763B0 . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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