Basic Information
| Provider Information | |||||||||
| NPI: | 1487159836 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARK NICOLLET HEALTH CARE PRODUCTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 PARK NICOLLET BLVD | ||||||||
| Address2: | 6WS01C | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936832 | ||||||||
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| Practice Location | |||||||||
| Address1: | 927 CHURCHILL ST W | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514304622 | ||||||||
| FaxNumber: | 9529930562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2018 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | BREY | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9529936832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARK NICOLLET | ||||||||
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| AuthorizedOfficialCredential: | DELEGATED OFFICIAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 6019472 | MN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.