Healthcare Provider Details

I. General information

NPI: 1619202934
Provider Name (Legal Business Name): PROVAX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 STONE CREEK DR
CHANHASSEN MN
55317-7410
US

IV. Provider business mailing address

2018 STONE CREEK DR
CHANHASSEN MN
55317-7410
US

V. Phone/Fax

Practice location:
  • Phone: 952-470-6005
  • Fax:
Mailing address:
  • Phone: 952-470-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberR106374-5
License Number StateMN

VIII. Authorized Official

Name: MRS. CINDY L EGELSTON
Title or Position: OWNER
Credential: R.N.
Phone: 952-470-6005