Healthcare Provider Details

I. General information

NPI: 1780735993
Provider Name (Legal Business Name): CENTRAL MINNESOTA SLEEP SPECIALISTS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 N 3RD ST
BRAINERD MN
56401-3054
US

IV. Provider business mailing address

PO BOX 750
NISSWA MN
56468-0750
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-7100
  • Fax:
Mailing address:
  • Phone: 218-963-7302
  • Fax: 218-961-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number35397
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number35397
License Number StateMN

VIII. Authorized Official

Name: DR. TODD MICHAEL GREATENS
Title or Position: CHIEF MANAGER AND CFO
Credential: M.D.
Phone: 218-963-7302