Healthcare Provider Details

I. General information

NPI: 1265802052
Provider Name (Legal Business Name): INTEGRATIVE IMMUNITY HEALTH SYSTEM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 W 69TH ST UNIT B
EDINA MN
55435-2001
US

IV. Provider business mailing address

625 W 18TH ST STE 100
SIOUX FALLS SD
57105-0602
US

V. Phone/Fax

Practice location:
  • Phone: 952-222-3879
  • Fax: 952-222-3919
Mailing address:
  • Phone: 952-222-3879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number56126
License Number StateMN

VIII. Authorized Official

Name: DR. BENOIT D TANO
Title or Position: MD/OWNER
Credential: MD
Phone: 952-222-3879