1407130248 NPI number — DIRECTIONS FOR LIFE PCA SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407130248 NPI number — DIRECTIONS FOR LIFE PCA SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIRECTIONS FOR LIFE PCA SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407130248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4897 MILLER TRUNK HWY STE 226
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMANTOWN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55811-1584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-722-1184
Provider Business Mailing Address Fax Number:
218-727-3677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4897 MILLER TRUNK HWY STE 226
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMANTOWN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811-1584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-1184
Provider Business Practice Location Address Fax Number:
218-727-3677
Provider Enumeration Date:
09/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MEILACH
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-722-1184

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  354301 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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