Healthcare Provider Details

I. General information

NPI: 1104800960
Provider Name (Legal Business Name): KENNETH GERARD FOGAL MS VP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 E MAIN ST CENTRAL LAKES MEDICAL CLINIC ,PA
CROSBY MN
56441-1691
US

IV. Provider business mailing address

318 E MAIN ST
CROSBY MN
56441-1691
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-8375
  • Fax: 218-546-4400
Mailing address:
  • Phone: 218-546-8375
  • Fax: 218-546-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0270
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: