Healthcare Provider Details

I. General information

NPI: 1265494777
Provider Name (Legal Business Name): PARK NICOLLET HEALTH CARE PRODUCTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14000 FAIRVIEW DR
BURNSVILLE MN
55337-5713
US

IV. Provider business mailing address

3800 PARK NICOLLET BLVD # MS 61901C
ST LOUIS PARK MN
55416-2527
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-8700
  • Fax: 952-993-0562
Mailing address:
  • Phone:
  • Fax: 952-993-0562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number StateMN

VIII. Authorized Official

Name: KRISTIN DENISE BREY
Title or Position: SUPERVISOR/DELEGATED OFFICIAL
Credential:
Phone: 952-993-6832