1710045430 NPI number — PROFESSIONAL RESOURCE NETWORK - PRN - CORPORATION

Table of content: (NPI 1710045430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710045430 NPI number — PROFESSIONAL RESOURCE NETWORK - PRN - CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL RESOURCE NETWORK - PRN - CORPORATION
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:
1710045430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
574 PRAIRIE CENTER DR STE 135-279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN PRAIRIE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55344-7930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-858-8807
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4951 W 77TH ST STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-4802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-858-8807
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEVOLITES
Authorized Official First Name:
CHARIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-858-8807

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  328388 , 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: 611727900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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