1871975607 NPI number — MINNESOTA HEAD AND NECK PAIN CLINIC, PA

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 1871975607 NPI number — MINNESOTA HEAD AND NECK PAIN CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA HEAD AND NECK PAIN CLINIC, PA
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:
1871975607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3475 PLYMOUTH BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55447-1499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-577-2484
Provider Business Mailing Address Fax Number:
763-577-1375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3475 PLYMOUTH BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55447-1499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-577-2484
Provider Business Practice Location Address Fax Number:
763-577-1375
Provider Enumeration Date:
06/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
REICHERT
Authorized Official First Name:
TIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHRO/CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
763-577-2484

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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