Basic Information
Provider Information
NPI: 1639826985
EntityType: 2
ReplacementNPI:  
OrganizationName: INFINITE HEALTH COLLABORATIVE, PA
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4200 DAHLBERG DR STE 300
Address2:  
City: GOLDEN VALLEY
State: MN
PostalCode: 554224841
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 5601 96TH AVE N STE 100
Address2:  
City: BROOKLYN PARK
State: MN
PostalCode: 554434505
CountryCode: US
TelephoneNumber: 7637869543
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/07/2022
LastUpdateDate: 03/07/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FERGUSON
AuthorizedOfficialFirstName: SARA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CREDENTIALING MANAGER
AuthorizedOfficialTelephone: 7633022007
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: INFINITE HEALTH COLLABORATIVE, PA
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: CPCS
NPICertificationDate: 03/07/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332B00000X  Y SuppliersDurable Medical Equipment & Medical Supplies 

No ID Information.


Home