Basic Information
Provider Information | |||||||||
NPI: | 1457946071 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARK NICOLLET HEALTH CARE PRODUCTS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3800 PARK NICOLLET BLVD # 6WS01C | ||||||||
Address2: |   | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554162527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529936832 | ||||||||
FaxNumber: | 9529930562 | ||||||||
Practice Location | |||||||||
Address1: | 537 PHALEN BLVD | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551305303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512546673 | ||||||||
FaxNumber: | 9529930562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2021 | ||||||||
LastUpdateDate: | 03/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BREY | ||||||||
AuthorizedOfficialFirstName: | KRISTIN | ||||||||
AuthorizedOfficialMiddleName: | DENISE | ||||||||
AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 9529936832 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DELEGATED OFFICIAL | ||||||||
NPICertificationDate: | 03/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.