1962687111 NPI number — VIOLET M. DEILKE

Table of content: (NPI 1962687111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962687111 NPI number — VIOLET M. DEILKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIOLET M. DEILKE
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:
DBA CENTRE FOR HAIR AND WELLNESS
Provider Other Organization Name Type Code:
3
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:
1962687111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 CENTER AVE
Provider Second Line Business Mailing Address:
SUITE #14
Provider Business Mailing Address City Name:
MOORHEAD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56560-1957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-236-6000
Provider Business Mailing Address Fax Number:
218-284-5889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 CENTER AVE
Provider Second Line Business Practice Location Address:
SUITE #14
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560-1957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-236-6000
Provider Business Practice Location Address Fax Number:
218-284-5889
Provider Enumeration Date:
01/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DEILKE
Authorized Official First Name:
VIOLET
Authorized Official Middle Name:
MARLENE
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
218-236-6000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  CO7557000 , 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)

  • Identifier: 1B4G361CE . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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