Basic Information
| Provider Information | |||||||||
| NPI: | 1609256122 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | B TEK, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6043 HUDSON RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519258200 | ||||||||
| FaxNumber: | 6519258201 | ||||||||
| Practice Location | |||||||||
| Address1: | 6043 HUDSON RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519258200 | ||||||||
| FaxNumber: | 6519258201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOWADA | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6519258200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 4059781 | MN | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.