Basic Information
| Provider Information | |||||||||
| NPI: | 1831145705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHEAST MEDICAL RESEARCH INSTITUTE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHEAST WOODBURY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1825 WOODWINDS DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512326700 | ||||||||
| FaxNumber: | 6512326711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 WOODWINDS DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512326700 | ||||||||
| FaxNumber: | 6512326711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 07/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | FROMM | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6126722258 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTHEAST MEDICAL RESEARCH INSTITUTE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0841630018 | 01 | MN | MEDICARE PTAN | OTHER | 779221200 | 05 | MN | MEDICAID |