Healthcare Provider Details

I. General information

NPI: 1912682279
Provider Name (Legal Business Name): LIONEL NJITOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6086 SUMMIT CURV S
COTTAGE GROVE MN
55016-4492
US

IV. Provider business mailing address

6086 SUMMIT CURV S
COTTAGE GROVE MN
55016-4492
US

V. Phone/Fax

Practice location:
  • Phone: 651-219-4362
  • Fax:
Mailing address:
  • Phone: 651-219-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44033
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: