Healthcare Provider Details

I. General information

NPI: 1629209226
Provider Name (Legal Business Name): MINNESOTA ORTHOTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 AVON AVE N
AVON MN
56310-8515
US

IV. Provider business mailing address

108 AVON AVE N
AVON MN
56310-8515
US

V. Phone/Fax

Practice location:
  • Phone: 320-293-2493
  • Fax:
Mailing address:
  • Phone: 320-293-2493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. TRENT ALLEN ZIMMERMAN
Title or Position: OWNER
Credential:
Phone: 320-293-2493