Healthcare Provider Details

I. General information

NPI: 1962440362
Provider Name (Legal Business Name): ESSENTIA HEALTH VIRGINIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W CONAN ST
ELY MN
55731-1145
US

IV. Provider business mailing address

300 W CONAN ST
ELY MN
55731-1145
US

V. Phone/Fax

Practice location:
  • Phone: 218-365-7900
  • Fax:
Mailing address:
  • Phone: 218-365-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL NIKCEVICH
Title or Position: PRESIDENT
Credential:
Phone: 218-786-2628