Basic Information
| Provider Information | |||||||||
| NPI: | 1316170277 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 CITY WEST PKWY | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443248 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 135 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157488100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7157488100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.