Healthcare Provider Details

I. General information

NPI: 1548730328
Provider Name (Legal Business Name): CHE DOUA THAO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LEAFLINE LABS
EAGAN MN
55425
US

IV. Provider business mailing address

935 LAWSON AVE E
SAINT PAUL MN
55106-3218
US

V. Phone/Fax

Practice location:
  • Phone: 651-846-9245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: