Basic Information
| Provider Information | |||||||||
| NPI: | 1306226576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INFINITE HEALTH COLLABORATIVE, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 TOWER DR W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550827583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512754180 | ||||||||
| FaxNumber: | 6512752744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2015 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIMONSON | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9525125639 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.