Healthcare Provider Details

I. General information

NPI: 1245516178
Provider Name (Legal Business Name): SPECIALIZAED MEDICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19679 CALGARY TRL
FARMINGTON MN
55024-1488
US

IV. Provider business mailing address

PO BOX 21715
EAGAN MN
55121-0715
US

V. Phone/Fax

Practice location:
  • Phone: 612-720-3824
  • Fax: 888-546-6978
Mailing address:
  • Phone: 612-720-3824
  • Fax: 888-546-6978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. KIRK EDWARD HANSON
Title or Position: CEO
Credential:
Phone: 612-720-3824