Basic Information
Provider Information | |||||||||
NPI: | 1487105995 | ||||||||
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 ZONE 3 | ||||||||
Address2: |   | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 55416 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529936832 | ||||||||
FaxNumber: | 9529930562 | ||||||||
Practice Location | |||||||||
Address1: | 1455 SAINT FRANCIS AVE | ||||||||
Address2: |   | ||||||||
City: | SHAKOPEE | ||||||||
State: | MN | ||||||||
PostalCode: | 553793374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529937644 | ||||||||
FaxNumber: | 9529930562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2016 | ||||||||
LastUpdateDate: | 10/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LENAGH | ||||||||
AuthorizedOfficialFirstName: | CATHERINE | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | VP, CFO | ||||||||
AuthorizedOfficialTelephone: | 9529933108 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PARK NICOLLET | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   | MN | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.