Healthcare Provider Details

I. General information

NPI: 1114374469
Provider Name (Legal Business Name): SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 S STATE ST STE 1000
FAIRMONT MN
56031-4469
US

IV. Provider business mailing address

717 S STATE ST STE 900
FAIRMONT MN
56031-4469
US

V. Phone/Fax

Practice location:
  • Phone: 507-235-3939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: COREY T WELCHLIN
Title or Position: OWNER PRESIDENT
Credential: DO
Phone: 507-238-4949