Healthcare Provider Details

I. General information

NPI: 1124296637
Provider Name (Legal Business Name): MS. LISA HAUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7758 JANERO COURT SOUTH
COTTAGE GROVE MN
55016
US

IV. Provider business mailing address

16492 FIVE HAWKS W. SE
PRIOR LAKE MN
55378
US

V. Phone/Fax

Practice location:
  • Phone: 651-549-5023
  • Fax:
Mailing address:
  • Phone: 952-447-6732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: