Healthcare Provider Details

I. General information

NPI: 1316147135
Provider Name (Legal Business Name): PARKSIDE HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 LYNDALE AVE S SUITE 105B
BLOOMINGTON MN
55420-2754
US

IV. Provider business mailing address

8609 LYNDALE AVE S SUITE 105B
BLOOMINGTON MN
55420-2754
US

V. Phone/Fax

Practice location:
  • Phone: 952-303-3104
  • Fax:
Mailing address:
  • Phone: 952-303-3104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateMN

VIII. Authorized Official

Name: MS. BEVERLY BUCKNER
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 952-303-3104