1740880764 NPI number — EAST METRO TRAUMA AND RECOVERY LLC

Table of content: (NPI 1740880764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740880764 NPI number — EAST METRO TRAUMA AND RECOVERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST METRO TRAUMA AND RECOVERY LLC
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:
1740880764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8154 ENCLAVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-3032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-590-4440
Provider Business Mailing Address Fax Number:
651-494-5915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4116 HOFFMAN RD
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:
55110-3708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-590-4440
Provider Business Practice Location Address Fax Number:
651-494-5915
Provider Enumeration Date:
10/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GRABER
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
612-590-4440

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2672 . This is a "BOARD OF MARRIAGE AND FAMILY THERAPY LICENSING BOARD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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