Basic Information
| Provider Information | |||||||||
| NPI: | 1497796072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEPLE | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 CHESHIRE LN N | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883339152 | ||||||||
| FaxNumber: | 7632684240 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 THOMPSON AVE E | ||||||||
| Address2: | # 204 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551183187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514559724 | ||||||||
| FaxNumber: | 6514559726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 5175 | MN | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237600000X | 2249 | MN | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 336365100 | 05 | MN | MEDICAID |