Healthcare Provider Details

I. General information

NPI: 1215635354
Provider Name (Legal Business Name): MYRIAH SHINDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6826 HUMBOLDT AVE N
BROOKLYN CENTER MN
55430-1536
US

IV. Provider business mailing address

PO BOX 29850
BROOKLYN PARK MN
55429-0850
US

V. Phone/Fax

Practice location:
  • Phone: 612-221-9350
  • Fax:
Mailing address:
  • Phone: 612-221-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: