Healthcare Provider Details

I. General information

NPI: 1982519302
Provider Name (Legal Business Name): MAI YIA LOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 SHINGLE CREEK XING STE B
BROOKLYN CENTER MN
55430-2851
US

IV. Provider business mailing address

26140 GALEN DR
WYOMING MN
55092-9341
US

V. Phone/Fax

Practice location:
  • Phone: 612-295-7218
  • Fax:
Mailing address:
  • Phone: 612-295-7218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number86054333
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: