Healthcare Provider Details

I. General information

NPI: 1356476444
Provider Name (Legal Business Name): EDWARD EUGENE DAIGLE M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 7TH ST NW
CASS LAKE MN
56633-3360
US

IV. Provider business mailing address

4567 WOLF LAKE DR SE
BEMIDJI MN
56601-7348
US

V. Phone/Fax

Practice location:
  • Phone: 218-335-3258
  • Fax: 218-335-3265
Mailing address:
  • Phone: 218-333-8651
  • Fax: 218-335-3265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: